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Situational Cues Surrounding Family Physicians Seeking External Resources While Self-Monitoring in Practice

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Title: Situational Cues Surrounding Family Physicians Seeking External Resources While Self-Monitoring in Practice
Language: English
Authors: Lee, Linda, King, Gillian, Freeman, Thomas, Eva, Kevin W.
Source: Advances in Health Sciences Education. Oct 2019 24(4):783-796.
Availability: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 14
Publication Date: 2019
Document Type: Journal Articles
Reports - Research
Descriptors: Cues, Physicians, Self Management, Help Seeking, Clinical Diagnosis, Family Practice (Medicine), Decision Making, Physician Patient Relationship, Medical Services, Expertise
DOI: 10.1007/s10459-019-09898-1
ISSN: 1382-4996
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.
Abstractor: As Provided
Entry Date: 2019
Accession Number: EJ1230258
Database: ERIC
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  Value: <anid>AN0138912234;oak01oct.19;2019Oct04.04:40;v2.2.500</anid> <title id="AN0138912234-1">Situational cues surrounding family physicians seeking external resources while self-monitoring in practice </title> <p>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.</p> <p>Keywords: Self-monitoring; Professional self-regulation; Maintenance of competence; Patient safety</p> <hd id="AN0138912234-2">Introduction</hd> <p>Many models of safe and effective clinical decision making in medical practice emphasize the importance of recognizing moments of uncertainty and seeking help accordingly (Eva and Regehr [<reflink idref="bib12" id="ref1">12</reflink>]; Moulton et al. [<reflink idref="bib29" id="ref2">29</reflink>]; Eva et al. [<reflink idref="bib16" id="ref3">16</reflink>]). In this regard there is an important distinction to be made between situation-specific self-monitoring (moment-by-moment assessments of one's likelihood of acting correctly) and self-assessment (an explicit overall judgment of one's ability; Eva and Regehr [<reflink idref="bib13" id="ref4">13</reflink>]). While literature convincingly suggests that the capacity for accurate self-assessment is poor, more recent study has suggested that individuals have considerable capacity for in-the-moment self-monitoring (Eva and Regehr [<reflink idref="bib15" id="ref5">15</reflink>]; McConnell et al. [<reflink idref="bib28" id="ref6">28</reflink>]; Pusic et al. [<reflink idref="bib33" id="ref7">33</reflink>]). That is, people appear generally to be more able to judge, in live time, how closely they are operating relative to the limits of their competence than they are of aggregating judgments across many such circumstances to generate an accurate overall impression of their ability. Most recently, data collected in the context of a computer-based medical school assessment illustrated the accuracy of self-monitoring to be driven more by context-specific factors such as the difficulty of a case presentation than by person-specific factors such as one's overall clinical ability (Hautz et al. [<reflink idref="bib20" id="ref8">20</reflink>]). This has important implications for models of professional self-regulation as it suggests the need to better understand what cues exist in different contexts that do or could prompt a physician to believe it important to access help from an external resource. Addressing this gap in understanding may provide valuable additional information about clinical decision-making and the self-monitoring process that is relevant to patient safety and medical education while also contributing to a greater understanding of psychosocial aspects of physician–patient encounters.</p> <p>The concept of self-monitoring is closely aligned with Schön's ([<reflink idref="bib35" id="ref9">35</reflink>]) notion of reflection-in-action in that the latter term describes an important and deliberate mechanism through which one can monitor performance to achieve awareness of the moments when one should slow down and/or seek external support to make a good clinical decision (Eva and Regehr [<reflink idref="bib14" id="ref10">14</reflink>]; Mamede et al. [<reflink idref="bib26" id="ref11">26</reflink>]). According to Schön, thinking about the activity in which one is engaged typically occurs when one is nervous about something new or unusual. That is, practitioners rarely formalize reflection-in-action such that its occurrence often implies a state of increased explicit awareness that an activity is not unfolding as expected. Little is known, however, regarding what cues prompt the monitoring that may take place implicitly to rise to the level of conscious reflection or the conclusion that one may have moved beyond the capacity to act without support.</p> <p>In this regard, a useful analogue has been generated over the past two decades as psychologists have explored similar issues in the context of how individuals self-monitor their learning (de Bruin et al. [<reflink idref="bib7" id="ref12">7</reflink>]). When we self-monitor whether or not we have the knowledge and skill to perform a particular task in practice we are effectively making judgments about whether or not we have sufficiently learned (including the capacity to adapt/transfer our understanding to new situations) the information or ability required to complete the task. During both practice and learning we form impressions of the extent to which relevant material is known and understood, but self-monitoring of practice is often separated further in time from the moment of learning relative to self-monitoring in learning. Nonetheless, in both instances we form our impressions by drawing inferences based on cues that are available. The cue-utilization framework put forward by Koriat et al. ([<reflink idref="bib23" id="ref13">23</reflink>]) organizes cues into those that are characteristic of the material being studied (i.e., Intrinsic cues such as difficulty of the material), cues related to environmental conditions (i.e., Extrinsic cues such as time pressure), and internal indicators of the likelihood that something is known (i.e., Mnemonic cues such as how readily something comes to mind). Fundamental to these ideas is that humans utilize cues like those described to monitor whether or not they will remember something because we cannot directly access the strength of a memory trace. Some cues provide meaningful information regarding the likelihood of success at a given task (i.e., they are diagnostic), but some are misleading. de Bruin et al. ([<reflink idref="bib7" id="ref14">7</reflink>]) offer a compelling case that clinical reasoning practices can be improved by better understanding what cues are effectively used to guide self-monitoring in health professional training and practice. Without such information, it is impossible to know how systems might be built to support professional efforts to self-regulate.</p> <p>As alluded to in the opening paragraph, studies within medical education have begun to suggest that cues that determine the effectiveness of self-monitoring are context specific. For example, Mamede et al. ([<reflink idref="bib26" id="ref15">26</reflink>], [<reflink idref="bib27" id="ref16">27</reflink>]) have demonstrated that physicians' switching from automatic to reflective reasoning processes tends to occur when a case is perceived as being complex or ambiguous. Pusic et al. ([<reflink idref="bib33" id="ref17">33</reflink>]) revealed that certainty in one's diagnostic ability does not decline as rapidly as performance after learners are taught radiograph interpretation, implying that the cues used to initially judge their certainty (with reasonable accuracy) were not effective in the context of contemplating the success of learning 2 weeks later. Hautz et al. ([<reflink idref="bib20" id="ref18">20</reflink>]) extended this work to show that students' struggle with a particular case provided a better cue as to the likelihood of their success than did their overall ability. All of these studies, however, are experimental in nature and, hence, provide insight only into the usefulness of cues that are built into the study design. In particular, such carefully controlled studies generally preclude insight into what extrinsic cues might be present and guiding health professionals when self-monitoring in a real-world context.</p> <p>Various authors have described the importance of a naturalistic approach to studying clinical decision-making, involving real-world situations which impose demands such as time pressures, fatigue and stress on the physicians' decision-making processes (Croskerry [<reflink idref="bib4" id="ref19">4</reflink>]; Wears [<reflink idref="bib36" id="ref20">36</reflink>]). Aligned with that suggestion, Moulton et al.'s ([<reflink idref="bib29" id="ref21">29</reflink>]) work characterized the concept of "slowing down when you should" during surgical procedures in an operating room setting as a way of exploring what prompted surgeons to move from "auto-pilot" to a more effortful cognitive state. In doing so they reported that many "slowing down" moments in surgery are proactively planned while situationally responsive moments are prompted by unexpected events with influence exerted by physician fatigue and confidence. "Slowing down" is presented in quotes because we follow Moulton et al. in using the phrase to reflect a movement towards more deliberate reflection whether or not a change in pace is actually observed. It is not necessarily the case, perhaps especially on non-procedural tasks, that literal speed is the best measure of the care with which one is performing a clinical act. In any case, to our knowledge, no studies have addressed the situational circumstances inducing physicians in non-procedural domains to "slow down". Such work is particularly important given that other domains of practice like primary care medicine involve a particularly broad scope of patient consultations that often occur in isolation with considerable time pressures and little to no opportunity to pre-plan, thereby yielding a high degree of uncertainty both in the right course of action and in one's capacity to choose a course of action.</p> <p>Using a naturalistic approach, this qualitative study was designed to identify situational, social, and personal factors that prompt physicians to access information from an external resource during moments of uncertainty. To capture factors in as close to live time as possible we armed family physicians with recording devices and a question guide. Given the novelty of this approach and the exploration of a wide array of influences that could impact upon the phenomenon of interest, we performed a generic thematic study guided by the principles common to many qualitative research methodologies (Kahlke [<reflink idref="bib22" id="ref22">22</reflink>]).</p> <hd id="AN0138912234-3">Methods</hd> <p></p> <hd id="AN0138912234-4">Methodological overview</hd> <p>The focus of this study was on exploring the cues that are present when physicians in practice perceive a need to consult external resources to support their efforts at providing healthcare in moments of uncertainty. Secondarily, we sought information regarding physicians' purpose when seeking such support and perceived impacts of doing so. Our approach, therefore, was interpretive with the goal of extracting a conceptual understanding of the cues that are present (internally or externally) when physicians feel compelled to consult resources beyond their personal knowledge. To that end, we adopted a generic qualitative research approach, as advocated by Kahlke ([<reflink idref="bib22" id="ref23">22</reflink>]) who argued that "Generic methods provide one space where researchers can play and make advances by deviating from methodological prescriptions, remaking existing methodologies and building approaches that may or may not become new methodologies". This was deemed particularly appropriate in this instance given the rarely used strategy (described below) of collecting data using participant activated recording devices, thereby allowing participant responses to be provided as close as possible to the moment in time being discussed.</p> <p>To allow for a variety of perspective and opportunity for conceptual debate regarding the meaning of the data collected, we formed a diverse research team composed of two family physicians with direct experience working in the same environment as the participants, a health services researcher from an affiliated health profession, and a cognitive scientist whose research interests have been heavily focused on the concepts and theories presented in the introduction. To minimize the influence of those theories, the latter investigator collaborated on the research design, but did not do any primary coding of the data and effort was made to search for disconfirming instances of the themes generated collaboratively by the research team.</p> <hd id="AN0138912234-5">Participants and recruitment</hd> <p>Family physicians were thought to be particularly valuable for studying the focal issue because they routinely interact with patients independently in their own offices and, hence, are frequently left fully to their own devices to determine when they require external support. In fact, core aspects of effective family practice include knowing how to act in moments of uncertainty and knowing when to refer to specialists (Freeman [<reflink idref="bib19" id="ref24">19</reflink>]).</p> <p>Given the exploratory nature of this study, we purposively sampled within the population of family physicians working in a variety of urban primary care clinics in Southwestern Ontario in an effort to achieve diversity of experience and perspective. That is, although the sample was drawn from a single geographic region, we sought a group of participants that included a mix of gender, practice structure (e.g., working in Family Health Teams with allied health care professionals, in traditional family physician group practices, or in solo practice), experience, and academic versus non-academic affiliations.</p> <p>A total of 16 physicians were approached to participate. Of the 12 who consented, 8 had academic affiliations (i.e., were involved in clinical workplace supervision of postgraduate trainees on behalf of a university-based family medicine training program). All physicians had similar access to current literature and external specialist physician supports as a result of the ease with which any physician in the studied region can access material on-line and specialist physician availability within their regional healthcare system. The participants with academic affiliations also had easy access to allied health professionals co-located within their primary care setting.</p> <hd id="AN0138912234-6">Procedure</hd> <p>Ethics approval was received from the Office of Research Ethics, Western University.</p> <p>Data were obtained from each participant through self-observational journaling. Each participant was provided with a recording device and a written set of instructions intended to serve as prompts to encourage elaboration on participants' descriptions of the circumstances, the nature of the external resource(s) accessed, and the influence of the resource on clinical decision-making during moments of sufficient uncertainty that they felt compelled to consult an external resource. The specific questions listed on the written instructions are illustrated in Box 1. They were generated through negotiation between the authors of this work with priority being given to developing a question set that was easy to understand, quickly focused on the topic of interest, and simple enough to answer (while not being closed-ended) that responding to each question would not be arduous between patient encounters. After a draft was created the questions were refined using feedback from clinical colleagues. We chose to not collect any data within this study regarding situations in which physicians did not feel compelled to consult external resources out of anticipation that the lack of opportunity to probe respondents' claims would yield only self-evident data such as "I didn't look it up because I knew the answer".</p> <p>Participants were instructed to turn on the recording device and speak into it immediately after 6 sequential patient encounters in which he or she felt compelled to use an external resource. An external resource was defined as any source of information beyond the individual physician's knowledge that was accessed to help make a clinical decision (e.g., electronic or book reference, specialist referral, obtaining the opinion of a colleague, etc.). Participants were told not to include any identifying patient information in their responses.</p> <hd id="AN0138912234-7">Analysis</hd> <p>Data were transcribed verbatim by a third party and reviewed by the researchers only after transcription to ensure anonymity. Participants were told this would be the process to increase the likelihood they would present honest accounts of their experiences. As data were collected, transcripts were reviewed periodically by the authors to identify themes. This took place using grounded theory principles in that we began open coding (reading through the transcripts and assigning tentative labels) and proceeded to axial coding (identifying relationships between the open codes and clustering/refining those codes to improve upon their parsimony). Each analyst took part in this process independently with key ideas and recurrent themes being aggregated periodically to allow further refinement and clarify points of discrepancy. This process progressed iteratively using constant comparison as new transcripts were collected with each new finding being compared against previously formed codes and findings in an effort to confirm and refute the emerging thematic structure.</p> <p>QSR NVivo 8 software ([<reflink idref="bib31" id="ref25">31</reflink>]) was used to facilitate the process of coding and retrieval and the cross indexing of sections of data with multiple themes. With this resource, the researchers met repeatedly as a group to compare and refine coding categories until a detailed coding framework was developed by which data could be systematically indexed. Data collection was stopped when theoretical sufficiency was achieved [i.e., once the established themes were deemed relevant and comprehensive with no new ideas emerging from continued data analysis; Pope et al. ([<reflink idref="bib32" id="ref26">32</reflink>])]. Member checking was completed by mailing a summary of results to each participant along with stamped return envelopes and a request to provide feedback on the degree to which the summary was consistent with the participants' impressions of their experience.</p> <hd id="AN0138912234-8">Results</hd> <p>Seventy-two narratives were collected from 12 family physicians practicing in the urban communities of Kitchener-Waterloo (11 participants) and Cambridge (1 participant) in Ontario, Canada. Six participants were male and 6 were female. Experience ranged from 2 to 21 years of practice (mean = 14 years). All participants were currently practicing community family physicians, 8 with academic affiliations with a Family Medicine residency teaching program. Eleven participants were in group practice and 1 practiced solo.</p> <p>This study provided information on the situational circumstances in primary care practice associated with physicians seeking external help in decision-making during moments of uncertainty. Tables 1 and 2 list common presentation cues and key information resources accessed, as cited by participants. Several important themes were identified: (<reflink idref="bib1" id="ref27">1</reflink>) Specific features of patient encounters cued physicians 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). (<reflink idref="bib2" id="ref28">2</reflink>) External resources were seen as an opportunity for verification, a mechanism to please patients, or a means through which to defend decision-making. (<reflink idref="bib3" id="ref29">3</reflink>) Accessing such resources appeared to have an influence on the physician–patient relationship.</p> <p>Common presentation cues that prompted physicians to seek external information</p> <p> <ephtml> <table frame="hsides" rules="groups"><tbody><tr><td align="left"><p>Case involves an unfamiliar condition</p></td></tr><tr><td align="left"><p>Case appears complex</p></td></tr><tr><td align="left"><p>Case involves a failure of previous treatment attempts</p></td></tr><tr><td align="left"><p>Case involves a potentially serious condition</p></td></tr><tr><td align="left"><p>Case in which the patient seems anxious or demanding</p></td></tr><tr><td align="left"><p>Case in which the person accompanying the patient seems anxious or demanding</p></td></tr><tr><td align="left"><p>Case in which the patient seems distrustful or dissatisfied with the diagnosis or proposed treatment plan</p></td></tr></tbody></table> </ephtml> </p> <p>Key information resources accessed by physicians</p> <p> <ephtml> <table frame="hsides" rules="groups"><tbody><tr><td align="left"><p>Reference manuals or textbooks</p></td></tr><tr><td align="left"><p>Internet sources</p></td></tr><tr><td align="left"><p>Ask a family physician colleague</p></td></tr><tr><td align="left"><p>Ask a specialist (informal consult)</p></td></tr><tr><td align="left"><p>Refer to a specialist (formal consult)</p></td></tr><tr><td align="left"><p>Refer to an allied health care professional</p></td></tr></tbody></table> </ephtml> </p> <p>Written instructions given to participants to guide their verbal journaling</p> <p> <ephtml> <table frame="hsides" rules="groups"><tbody><tr><td align="left"><p>For the next 6 patient encounters in which you utilize an external source of knowledge in helping to make a clinical decision (e.g., electronic or book reference, referral because the diagnosis was unclear, obtained the opinion of a colleague, etc.), please comment on the following as soon as possible after the encounter:</p></td></tr><tr><td align="left"><p>(1) Description of circumstances</p></td></tr><tr><td align="left"><p>Leaving out identifying patient information, describe the circumstances at the time in which you felt the need to use an external source of information</p></td></tr><tr><td align="left"><p> ∙ What aspect(s) of the patient's case provided the source of your uncertainty?</p></td></tr><tr><td align="left"><p> ∙ Was there anything unusual about this case that led you to use an external resource?</p></td></tr><tr><td align="left"><p> ∙ Was there anything unusual about your own background with this type of case that led you to use an external resource?</p></td></tr><tr><td align="left"><p> ∙ Were there environmental circumstances that influenced your decision to use external sources of information in this case?</p></td></tr><tr><td align="left"><p>(2) Nature of resource(s) used</p></td></tr><tr><td align="left"><p> ∙ What external resource(s) did you use?</p></td></tr><tr><td align="left"><p>(3) Influence of the resource on decision-making</p></td></tr><tr><td align="left"><p> ∙ What information were you seeking?</p></td></tr><tr><td align="left"><p> ∙ Are there other resources you would have liked to have used/considered using, but didn't? If so, why?</p></td></tr><tr><td align="left"><p> ∙ Did utilizing the resource(s) affect your clinical decision?</p></td></tr><tr><td align="left"><p> ∙ How important was it that you utilized external resources rather than pressing on without them?</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0138912234-9">Features of patient encounters that cued physicians to seek external information</hd> <p>Specific features of patient encounters that cued physicians to access external sources for help in the moment of interacting with a patient were multifaceted. Medical aspects included unusual or complex presentations, potentially serious conditions, and failure of previous treatment attempts.</p> <p>So, it was just the unusual features of this rash that did not fall into a typical pattern that we usually see and that is what made me feel that I would like some extra information on this [Dr. I]</p> <p>She has had ongoing pain issues...The uncertainty was really on how to manage this as she has been tried on medication, physiotherapy, chiropractic treatment and massage [Dr. A]</p> <p>The family history of melanoma raised a red flag. My feeling was that I didn't want to miss anything [Dr. J]</p> <p>Social pressures played a considerable role and were particularly noted when the patient or others attending with the patient were perceived as being anxious, demanding, or mistrustful.</p> <p>A 35 years old woman with a history of chronic constipation who has a friend of a similar age who has been diagnosed with metastatic cancer of the colon and is therefore extremely anxious about her chronic constipation [Dr. H]</p> <p>The pressure and the seriousness of the case were compounded by the concern I felt from the patient's son [Dr. J]</p> <p>Importantly, these social pressures also appeared to be felt from the presence of others who were unrelated to the patient including learners or even the virtual presence of others such as the anticipation of legal involvement.</p> <p>Because I was in a teaching role, I felt it was important that the information that I was sharing was accurate and so I felt that I needed to be a little more certain than I would normally [Dr. G]</p> <p>This case involved considering a situation that was uncertain in regards to whether there was any neglect or child abuse going on. Because of the medical legal implications I needed more certainty in terms of what to do [Dr. C]</p> <p>With regard to personal factors, the physicians indicated an influence of self-identified gaps in personal knowledge or experience (either at general or case specific levels) and personal needs to achieve greater certainty in their decision-making.</p> <p>I am particularly weak in Rheumatologic diseases and I am aware of that and therefore I looked it up on the internet and ended up looking at my Toronto Notes and eMedicine [Dr. E]</p> <p>Generally, skin rashes are very easy to diagnose, but in this case, I am just totally unsure what is going on [Dr. K]</p> <p>In many cases I think it was easing my own concerns as opposed to the patient's who seem quite fine with that approach [Dr. L].</p> <hd id="AN0138912234-10">The use of external information as an opportunity and a defense mechanism</hd> <p>Access to external resources often acted as an opportunity for verification of the diagnosis or management plans. In fact, most physicians reported feeling reassured with their decisions after accessing the external resource rather than reporting that the resource fundamentally changed their opinion. They frequently described a sense of knowing the answer but wanting reassurance from an external resource to help "'back up' my gut feeling" or to "support my inclination with this particular patient". The value of verification was especially noted in cases representing a serious condition or one that could have potentially serious consequences associated with incorrect diagnosis or management; in those cases, several physicians described concerns about the consequences of incorrect diagnoses and mismanagement. In some cases, again, the potential for legal liability and the presence of learners were considerations.</p> <p>I went on the internet to find information and pictures to show the mother to reinforce the clinical diagnosis. ...It didn't really affect my decision making but it did help give the patient and my student information ... and helped confirm the diagnosis and plan of treatment [Dr. E]</p> <p>Two additional reasons were identified as indications of why physicians felt a need to access external resources: a desire to please or a desire to defend. In some cases, physicians described a greater need to foster patient trust and satisfaction with care, with access to external resources providing a means of alleviating patient anxiety. This was particularly noted as a reason for accessing specialists' consultation, either by telephone discussion between the family physician and specialist or actual referral of the patient to a specialist.</p> <p>When I spoke with the patient I knew that she would be anxious, and I was able to explain to her the suggestions from the gynecologist so it was very helpful to say that I had spoken with somebody who was a specialist in the area, which increased the level of credibility, and the patient's comfort [Dr. G]</p> <p>In other cases involving anxiety of the patient or accompanying person, physicians described a greater need to defend his or her own actions and decision-making. This was particularly noted in cases involving a sense of patient mistrust.</p> <p>Certainly in my experience with this particular patient, she has had some medical events that have made her quite distrustful of the medical system and so on and [I am] probably more likely to refer her sooner rather than later, even though medically I am not concerned that there is something sinister going on [Dr. H]</p> <p>The patient feels that I missed her Melanoma, so that in turn puts extra pressure to be certain about making any clinical decisions. I feel that the patient doesn't fully trust me and therefore I think that is what increases my angst about making correct decisions about her care [Dr. E].</p> <hd id="AN0138912234-11">Influences on the patient-physician relationship</hd> <p>While the reasons given were variable, most reported that accessing external information would be expected to have a positive impact on the physician–patient relationship. In some circumstances, obtaining accurate information was important for the quality of care. In others, it was about maintaining patient trust and satisfaction. In others still, accessing external information contributed to a sense of appearing more knowledgeable in front of the patient.</p> <p>I just think that I was very concerned about not causing this chronically ill patient any more problems by causing a medication reaction [Dr. I]</p> <p>I felt some pressure from her and from her dislike of the cardiologist. I felt like the patient physician relationship would have been impaired if I didn't take her concerns seriously since she was very adamant that she felt one medication was the culprit [Dr. J]</p> <p>I felt a significant amount of pressure because the patient was with me [and] I wanted to look professional and I wanted to be quite certain about any advice that I would give the patient [Dr. E]</p> <p>In general, our participants openly disclosed their feelings of uncertainty to their patients.</p> <p>It was toward the end of a very busy morning and I had patients to see, and I was running behind. Rather than giving a flippant answer, I suggested that she follow up and allow me some time to look up treatment [Dr. G].</p> <hd id="AN0138912234-12">Discussion</hd> <p>This study explored the situational circumstances of clinical uncertainty in which participants perceived a need for help with their decision-making. The results highlight the importance of medical, social and personal factors as influencing physicians' seeking access to external resources and suggest that access to such resources fills not only the medical needs of patients, but also the psychosocial needs of both patients and physicians. While many studies have demonstrated the influence of a variety of factors in clinical decision-making most have focused on the medical aspects of the case such as the urgency (Davies [<reflink idref="bib6" id="ref30">6</reflink>]) or ambiguity (Barsky et al. [<reflink idref="bib1" id="ref31">1</reflink>]) of the presenting problem and comparatively little has been written on social influences on physician resource use (Forrest et al. [<reflink idref="bib18" id="ref32">18</reflink>]; Salmon et al. [<reflink idref="bib34" id="ref33">34</reflink>]). With increasing emphasis being placed on encouraging trainees and physicians to develop the habit of seeking external data to inform their own assessment of their practice it is necessary to understand what cues are used to prompt external resource use and which of those cues provide meaningful information.</p> <p>The importance of social influences was particularly noted when the patient or others attending with the patient were perceived as being anxious, demanding, or mistrustful. Several physicians described feelings of significant patient pressure in influencing their decision to access an external resource such as specialist referral. Literature supports the desire to foster patient trust and satisfaction with care as a factor motivating a significant number (14–20%) of referrals (Donohoe et al. [<reflink idref="bib8" id="ref34">8</reflink>]; Forrest et al. [<reflink idref="bib18" id="ref35">18</reflink>]). That said, there has been little written about the mechanism of this influence (Donohoe et al. [<reflink idref="bib8" id="ref36">8</reflink>]; Forrest et al. [<reflink idref="bib18" id="ref37">18</reflink>]). While the desire to please, the desire to defend, and the desire for verification were present as competing hypotheses offering a mechanism of influence under these circumstances, there is little reason to believe that only one mechanism will be functional.</p> <p>The data collected in this study do not allow us to determine if seeking external support in the instances that were recorded was important, valuable, necessary, inefficient, wasteful, or somewhere else along that continuum. As the complexity of patient care grows due to new technologies, rising costs, and aging populations, among other things, it becomes increasingly important that the professions engage in further study to determine how to direct the training and assessment of competencies related to effective and efficient health system resource utilization in a way that satisfies both patient and physician needs. Physicians' feelings of a need to defend decision-making may be reduced through the continued shift of the physician–patient relationship from a paternalistic model to more current models of care in which the physician's role is likened to that of a coach (Emanuel and Emanuel [<reflink idref="bib10" id="ref38">10</reflink>]; Lovell [<reflink idref="bib25" id="ref39">25</reflink>]). That said, the desires to meet the demands of patients and to verify one's conceptions of the clinical scenario may increase the rate at which physicians feel compelled to draw upon the external supports examined in this study. In any case, learning to disclose uncertainty when it is appropriate to do so and, more generally, learning to indicate how and which external supports can be used to enhance relationship-centred care in ways that do not undermine patient confidence in their physician may also be fruitful for both educational programs and licensing/certification bodies (Johnson et al. [<reflink idref="bib21" id="ref40">21</reflink>]).</p> <p>In the present study, access to external resources also appeared to alleviate the physician's own anxiety. Physicians frequently described a sense of knowing the answer but wanting reassurance, with information provided by the external resource serving that function. This could be seen as evidence of confirmation bias. However, this tendency was particularly noted in cases in which seeking verification would seem appropriate (i.e., those involving potentially serious medical conditions). In these cases, several physicians described concerns about the consequences of incorrect diagnosis and management. Such findings may support concepts of the "chagrin factor" and "regret theory" described in the literature. These theories suggest that physician anxiety about missing an important diagnosis and subsequent regret are important considerations in the ordering of referrals and investigations and can be significant factors affecting rational, probabilistic decision-making (Feinstein [<reflink idref="bib17" id="ref41">17</reflink>]; Bell [<reflink idref="bib2" id="ref42">2</reflink>]). Other comments reflect a mindfulness about personal influences and the need for obtaining further information (Longhurst [<reflink idref="bib24" id="ref43">24</reflink>]; Epstein [<reflink idref="bib11" id="ref44">11</reflink>]). Several physicians' comments demonstrated the concept of critical tension in various ways such as needing to "reassure myself that I wasn't missing anything", "it is more an internal pressure, not an external pressure," and a feeling of "groping in the dark for answers" (Borell-Carrio and Epstein [<reflink idref="bib3" id="ref45">3</reflink>]) Taken together, the current findings extend these theories by suggesting an interaction between cognitive and social aspects of practice. That is, rather than anticipated regret focusing simply on achieving a suboptimal outcome (as might be implied if participants had simply been seeking knowledge), our respondents made it clear from the range of reasons they gave for consulting external resources that the action of doing so serves very social functions like saving face, reassuring the patient, and constructing a rationale/justification that would be defensible to others.</p> <p>Studies have suggested that access variables such as availability, searchability, understandability, and clinical applicability are more related to the physician's use of resources than qualities such as extensiveness and credibility of that resource (Curley et al. [<reflink idref="bib5" id="ref46">5</reflink>]). Convenience and time required to find relevant and clinically useful information appear to be particularly important factors influencing physicians' use of a resource (Northup et al. [<reflink idref="bib30" id="ref47">30</reflink>]; Ely et al. [<reflink idref="bib9" id="ref48">9</reflink>]). These issues have a number of implications for the design of the health care system overall and point to the importance of establishing a supportive peer network through which individual practitioners can safely and easily access trusted colleagues for advice, feedback, and the opportunity for spontaneous learning to take place.</p> <p>As a qualitative study involving a relatively small number of community-based family physician participants (over half of whom had academic affiliations), the results may not be transferable to all physicians in other settings and, as an exploratory study, conclusions cannot be drawn regarding the relative importance of the situational cues or types of resources accessed. That said, the participants were all primarily community physicians (i.e., their "academic affiliation" alludes simply to the fact that they take trainees into their workplace, which is true for over half of family physicians in Canada). Further, the majority of resources they claim to have used are accessible to all physicians in our healthcare system and responses to the question of "were there other resources you would have liked to have used?" did not suggest that any of our participants, academically affiliated or otherwise, felt limited in their capacity to access the external resources they desired to grapple with the moments of uncertainty studied. A second limitation is that the results may be dependent on the subset of patient encounters on which physicians were asked to report. Physicians were asked to comment on patients with whom they chose to seek external resources without any reference being requested to what cues were present when physicians felt certainty or chose not to consult external resources despite feelings of uncertainty. How prevalently some of the same features may have been present in other cases and whether or not external resources should have been sought in those other cases cannot be determined without further study. Finally, it should also be noted that the need to provide set and guiding written instructions may have cued the physician towards particular responses. The methods adopted did not allow the investigators to interrogate particular answers or re-direct responses to elaborated responses, yielding the potential that the thematic results identified were influenced by the particular questions provided. Future research could include follow-up interviews. While doing so would temporally separate the data collection from the lived experience to a greater extent, the lack of time stamps on our recordings prevent certainty regarding how much of a delay actually existed within our dataset.</p> <p>Although the methodology is subject to these limitations, unlike most studies that use retrospective generic techniques for information collection, we attempted to minimize these weaknesses by arming physicians with recording devices to capture their in-the-moment thinking about cues that prompted the behavioral outcome of seeking information from an external resource. As well, a set of questions acted as prompts to encourage an accurate and detailed description of the circumstances of the case. For these reasons, we believe the results meaningfully advance knowledge of important situational circumstances that prompt the family physician to access external resources in moments of uncertainty.</p> <p>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.</p> <hd id="AN0138912234-13">Acknowledgements</hd> <p>The authors would like to thank the family physicians who participated in this study for their time and support.</p> <hd id="AN0138912234-14">Compliance with ethical standards</hd> <p></p> <hd id="AN0138912234-15">Ethical approval</hd> <p>This study was approved by the Office of Research Ethics at Western University.</p> <hd id="AN0138912234-16">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0138912234-17"> <title> References </title> <blist> <bibl id="bib1" idref="ref27" type="bt">1</bibl> <bibtext> Barsky AJ, Ettner SL, Horsky J, Bates DW. 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  Data: Situational Cues Surrounding Family Physicians Seeking External Resources While Self-Monitoring in Practice
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  Data: <searchLink fieldCode="SO" term="%22Advances+in+Health+Sciences+Education%22"><i>Advances in Health Sciences Education</i></searchLink>. Oct 2019 24(4):783-796.
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  Data: Springer. Available from: Springer Nature. 233 Spring Street, New York, NY 10013. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-348-4505; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: 10.1007/s10459-019-09898-1
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  Data: 1382-4996
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  Data: 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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      – SubjectFull: Self Management
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      – SubjectFull: Help Seeking
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      – TitleFull: Situational Cues Surrounding Family Physicians Seeking External Resources While Self-Monitoring in Practice
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      – PersonEntity:
          Name:
            NameFull: Eva, Kevin W.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 10
              Type: published
              Y: 2019
          Identifiers:
            – Type: issn-print
              Value: 1382-4996
          Numbering:
            – Type: volume
              Value: 24
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: Advances in Health Sciences Education
              Type: main
ResultId 1