Patient-Care Questions that Physicians Are Unable to Answer

ObjectiveTo describe the characteristics of unanswered clinical questions and propose interventions that could improve the chance of finding answers.DesignIn a previous study, investigators observed primary care physicians in their offices and recorded questions that arose during patient care. Questions that were pursued by the physician, but remained unanswered, were grouped into generic types. In the present study, investigators attempted to answer these questions and developed recommendations aimed at improving the success rate of finding answers.MeasurementsFrequency of unanswered question types and recommendations to increase the chance of finding answers.ResultsIn an earlier study, 48 physicians asked 1062 questions during 192 half-day office observations. Physicians could not find answers to 237 (41%) of the 585 questions they pursued. The present study grouped the unanswered questions into 19 generic types. Three types accounted for 128 (54%) of the unanswered questions: (1) “Undiagnosed finding” questions asked about the management of abnormal clinical findings, such as symptoms, signs, and test results (What is the approach to finding X?); (2) “Conditional” questions contained qualifying conditions that were appended to otherwise simple questions (What is the management of X, given Y? where “given Y” is the qualifying condition that makes the question difficult.); and (3) “Compound” questions asked about the association between two highly specific elements (Can X cause Y?). The study identified strategies to improve clinical information retrieval, listed below.ConclusionTo improve the chance of finding answers, physicians should change their search strategies by rephrasing their questions and searching more clinically oriented resources. Authors of clinical information resources should anticipate questions that may arise in practice, and clinical information systems should provide clearer and more explicit answers.     

Providing evidence-based answers to clinical questions. A pilot information service for general practitioners

OBJECTIVE: To pilot a clinical information service for general practitioners. METHODS: A representative sample of 31 GPs was invited to submit clinical questions to a local academic department of general practice. Their views on the service and the usefulness of the information were obtained by telephone interview. RESULTS: Over one month, nine GPs (29% of the sample, 45% of those stating an interest), submitted 20 enquiries comprising 45 discrete clinical questions. The median time to search for evidence, appraise it and write answers to each enquiry was 2.5 hours (range, 1.0-7.4 hours). The median interval between receipt of questions and dispatch of answers was 3 days (range, 1-12 days). CONCLUSIONS: The GPs found the answers useful in clinical decision making; in four out of 20 cases patient management was altered.     

Effectiveness of Clinician-selected Electronic Information Resources for Answering Primary Care Physicians’ Information Needs

ObjectiveTo determine if clinician-selected electronic information resources improve primary care physicians’ abilities to answer simulated clinical questions.DesignObservational study using hour-long interviews in physician offices and think-aloud protocols. Participants answered 23 multiple-choice questions and chose 2 to obtain further information using their own information resources. We established which resources physicians chose, processes used, and results obtained when looking for information to support their answers.MeasurementsCorrectness of answers before and after searching, resources used, and searching techniques.Results23 physicians sought answers to 46 questions using their own information resources. They spent a mean of 13.0 (SD 5.5) minutes searching for information for the two questions using an average of 1.8 resources per question and a wide variety of searching techniques. On average 43.5% of the answers to the original 23 questions were correct. For the questions that were searched, 18 (39.1%) of the 46 answers were correct before searching. After searching, the number of correct answers was 19 (42.1%). This difference of 1 correct answer was attributed to 6 questions (13.0%) going from an incorrect to correct answer and 5 (10.9%) questions going from a correct to incorrect answer. We found differences in the ability of various resources to provide correct answers.ConclusionFor the primary care physicians studied, electronic information resources of choice did not always provide support for finding correct answers to simulated clinical questions and in some instances, individual resources may have contributed to an initially correct answer becoming incorrect.     

重症监护病房临床信息系统的应用

作为临床信息系统的重要组成部分。重症监护临床信息系统能有效提高监护室护理的工作效率和质量,使重症监护工作更加准确、安全。介绍了该系统的内容、特点、流程及与医院信息系统（HIS）的集成，通过该系统在我院重症监护病房（ICU）的应用。实现了重症监护过程的规范化和数字化管理。使医疗信息、重症监护信息充分共享，收到了很好的效果。     

全科医生临床实践中知识型临床问题的处理现状研究

背景　当前国内大力推进分级诊疗,难点之一是提高全科医生的首诊能力,研究全科医生在日常临床实践中需解决的问题,有助于提供针对性的辅助,提高其岗位胜任力。目的　调查全科医生临床实践中遇到知识型临床问题的频率及处理现状。方法　于2020年2-4月,采用便利抽样法对参加全科医师协会活动的300名医生进行线上问卷调查,了解其遇到知识型临床问题的频率、种类和处理方式,并采用多因素Logistic回归分析影响问题查询率和解答率的因素。结果　回收有效问卷297份（99.0%）,其中女性医生、中高级职称医生、工作10年以上者分别占69.7%（207/297）、75.2%（221/294）和48.5%（144/297）。117例（39.4%）全科医生经常或每天遇到无法现场解答的临床问题,约每接诊4.6名患者遇到1个问题;最常见的问题涉及药品使用、病理生理、鉴别诊断和疾病诊断。仅50.7%（150/296）全科医生会查询大部分（>60%）问题;仅12.9%（38/296）能找到>80%的问题答案,主要查询途径是教科书、通用搜索网站（如百度）、咨询他人;91例（30.6%）报告工作场所提供专业信息检索工具。多因素Logistic回归分析结果显示单元接诊量较少、遇到问题频率较低和习惯检索专业信息的医生更可能查找问题（P<0.05）;遇到问题频率较低和积极查询问题者找到正确答案的比例更高（P<0.05）。结论　全科医生在临床实践中遇到知识型临床问题而未得到有效解答的现象常见,主要包括诊断和治疗方面的问题。缺乏时间和高效率的问题检索习惯是妨碍临床问题解答的主要影响因素。     

Feasibility of an evidence-based literature search service for general practitioners

OBJECTIVE: To test the feasibility of an evidence-based clinical literature search service to help answer general practitioners' (GPs') clinical questions. DESIGN: Two search services supplied GPs who submitted questions with the best available empirical evidence to answer these questions. The GPs provided feedback on the value of the service, and concordance of answers from the two search services was assessed. SETTING: Two literature search services (Queensland and Victoria), operating for nine months from February 1999. MAIN OUTCOME MEASURES: Use of the service; time taken to locate answers; availability of evidence; value of the service to GPs; and consistency of answers from the two services. RESULTS: 58 GPs asked 160 questions (29 asked one, 11 asked five or more). The questions concerned treatment (65%), aetiology (17%), prognosis (13%), and diagnosis (5%). Answering a question took a mean of 3 hours 32 minutes of personnel time (95% CI, 2.67-3.97); nine questions took longer than 10 hours each to answer, the longest taking 23 hours 30 minutes. Evidence of suitable quality to provide a sound answer was available for 126 (79%) questions. Feedback data for 84 (53%) questions, provided by 42 GPs, showed that they appreciated the service, and asking the questions changed clinical care. There were many minor differences between the answers from the two centres, and substantial differences in the evidence found for 4/14 questions. However, conclusions reached were largely similar, with no or only minor differences for all questions. CONCLUSIONS: It is feasible to provide a literature search service, but further assessment is needed to establish its cost effectiveness.     

我国基层医疗卫生机构医护人员的医防整合行为及影响因素研究

背景　构建医防整合型卫生服务体系,基层卫生服务不可或缺,医护人员在服务过程中的行为直接影响患者接受服务的质量和健康状况,揭示整合服务行为的影响因素对准确、科学制定医防整合服务政策有重要意义。目的　分析基层医护人员的医防整合行为及其影响因素,为加强基层医防整合服务提供政策建议。方法　于2019年4-10月,采用全国性多阶段抽样,使用自设问卷对基层医护人员进行调查,主要包括基本信息、医防整合认识和服务行为指标等,利用两水平线性回归和多元线性回归模型分析服务行为的影响因素。结果　共计发放问卷810份,基层医护人员自报预防服务时间占比有效问卷数量是624份,有效率为77.4%;固定患者服务比例有效问卷数量是609份,有效率为75.2%。基层医护人员自报预防服务时间占比和固定患者服务比例的均值分别为（37.7±23.033）%和（27.3±24.312）%。预防服务时间占比资料层级结构明显,两水平线性回归模型结果显示日常服务过程中的预防服务时间占比影响因素包括是否参与家庭医生团队、合作互动和专业界限认识（P<0.05）;多元线性回归模型获得的固定患者服务比例影响因素包括人员类型、是否参与家庭医生团队、合作互动和本机构工作年限（P<0.05）。结论　推进家庭医生团队建设和签约服务;明确服务分工,加强科室和多学科合作;转变医防人为分割的固化思维等有利于医务人员为患者提供连续协调的医防整合服务。     

Psychiatry in general practice. A pilot scheme using the liaison-attachment model.

OBJECTIVE: To improve the quality and accessibility of psychiatric service in the primary care setting. DESIGN: Under the liaison-attachment model, a senior psychiatry trainee provided psychiatric consultations part-time in general practice over an 18-month period. Patients regarded by the participating doctors as having significant psychiatric problems were referred to the trainee for consultation. SETTING: Four group general practices, involving 18 doctors, took part in the scheme. PARTICIPANTS: During the study 172 patients with a wide spectrum of diagnoses were assessed. Near the end of the 18-month period the participating general practitioners provided their evaluations of the scheme. INTERVENTION: In almost all cases standard treatment was provided in the primary care setting and administered by either a general practitioner, the trainee or both working collaboratively together. OUTCOME MEASURES: The general practitioners evaluated the results of the consultations and the effect of the service on their referral patterns. They also rated the overall impact of the scheme on their own knowledge and skills, the quality of care, and its accessibility. RESULTS: The quality of outcome, if known, was regarded as satisfactory in 88% of cases. The reported frequency of referrals to psychiatrists in private practice dropped significantly. The participating doctors perceived improvements in their own abilities to deal with psychiatric problems and regarded the quality and accessibility of psychiatric care to be enhanced by the scheme. CONCLUSIONS: The psychiatric liaison-attachment model, developed in Britain, is applicable and effective in the Australian primary care setting.     

Clinical Decision Velocity is Increased when Meta-search Filters Enhance an Evidence Retrieval System

Objective

To test whether the use of an evidence retrieval system that uses clinically targeted meta-search filters can enhance the rate at which clinicians make correct decisions, reduce the effort involved in locating evidence, and provide an intuitive match between clinical tasks and search filters.

Design

A laboratory experiment under controlled conditions asked 75 clinicians to answer eight randomly sequenced clinical questions, using one of two randomly assigned search engines. The first search engine Quick Clinical (QC) was equipped with meta-search filters (the combined use of meta-search and search filters) designed to answer typical clinical questions e.g., treatment, diagnosis, and the second ‘library model’ system (LM) offered free access to an identical evidence set with no filter support.

Measurements

Changes in clinical decision making were measured by the proportion of correct post-search answers provided to questions, the time taken to answer questions, and the number of searches and links to documents followed in a search session. The intuitive match between meta-search filters and clinical tasks was measured by the proportion and distribution of filters selected for individual clinical questions.

Results

Clinicians in the two groups performed equally well pre-search. Post search answers improved overall by 21%, with 52.2% of answers correct with QC and 54.7% with LM (χ² = 0.33, df = 1, p > 0.05). Users of QC obtained a significantly greater percentage of their correct answers within the first two minutes of searching compared to LM users (QC 58.2%; LM 32.9%; χ² = 19.203, df = 1, p < 0.001). There was a statistical difference for QC and LM survival curves, which plotted overall time to answer questions, irrespective of answer (Wilcoxon, p = 0.019) and for the average time to provide a correct answer (Wilcoxon, p = 0.006). The QC system users conducted significantly fewer searches per scenario (m = 3.0 SD = 1.15 versus m = 5.5 SD1.97, t = 6.63, df = 72, p = 0.0001). Clinicians using the QC system followed fewer document links than did those who used LM (respectively 3.9 links SD = 1.20 versus 4.7 links SD = 1.79, t = 2.13, df = 72, p = 0.0368). In 6 of the 8 questions, two meta-search filters accounted for 89% or more of clinicians'' first choice, suggesting the choice of filter intuitively matched the clinical decision task at hand.

Conclusions

Meta-search filters result in clinicians arriving at answers more quickly than unconstrained searches across information sources, and appear to increase the rate with which correct decisions are made. In time restricted clinical settings meta-search filters may thus improve overall decision accuracy, as fewer searches that could otherwise lead to a correct answer are abandoned. Meta-search filters appear to be intuitive to use, suggesting that the simplicity of the user model would fit very well into clinical settings.     

Research and applications: Resident physicians as human information systems: sources yet seekers

Objective

To characterize question types that residents received on overnight shifts and what information sources were used to answer them.

Materials and Methods

Across 30 overnight shifts, questions asked of on-call senior residents, question askers’ roles, and residents’ responses were documented. External sources were noted.

Results

158 of 397 questions (39.8%) related to the plan of care, 53 (13.4%) to medical knowledge, 48 (12.1%) to taskwork knowledge, and 44 (11.1%) to the current condition of patients. For 351 (88.4%) questions residents provided specific, direct answers or visited the patient. For 16 of these, residents modeled or completed the task. For 216 questions, residents used previous knowledge or their own clinical judgment. Residents solicited external information sources for 118 questions and only a single source for 77 (65.3%) of them. For the 118, most questions concerned either the plan of care or the patient''s current condition and were asked by interns and nurses (those with direct patient care responsibilities).

Discussion

Resident physicians serve as an information system and they often specifically answer the question using previous knowledge or their own clinical judgment, suggesting that askers are contacting an appropriately knowledgeable person. However, they do need to access patient information such as the plan of care. They also serve an educator role and answer many knowledge-related questions.

Conclusions

As synchronous verbal communications continue to be important pathways for information flow, informaticians need to consider the relationship between such communications and workflow in the development of healthcare support tools.     

Diagnosing skin cancer in primary care: how do mainstream general practitioners compare with primary care skin cancer clinic doctors?

OBJECTIVE: To measure and compare the casemix and diagnostic accuracy of excised or biopsied skin lesions managed by mainstream general practitioners and doctors within primary care skin cancer clinics. DESIGN, SETTING AND PARTICIPANTS: Prospective comparative study of 104 GPs and 50 skin cancer clinic doctors in south-eastern Queensland, involving 28 755 patient encounters. The study was conducted in 2005. MAIN OUTCOME MEASURES: Prevalence of each type of skin lesion; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the clinical diagnosis against histology; number needed to excise or biopsy (NNE) for a diagnosis of skin cancer. RESULTS: GPs excised or biopsied 3175 skin lesions (mean 2.5/week) including 743 basal cell carcinomas (BCCs) (23.4%), 704 squamous cell carcinomas (SCCs) (22.2%) and 49 melanomas (1.5%). Skin cancer clinic doctors excised or biopsied 7941 skin lesions (mean 34/week), including 2701 BCCs (34.0%), 1274 SCCs (16.0%) and 103 melanomas (1.3%). Overall, sensitivity for diagnosing any skin cancer was similar for skin cancer clinic doctors (0.94) and GPs (0.91), although higher for skin cancer clinic doctors for BCC (0.89 v 0.79; P < 0.01) and melanoma (0.60 v 0.29; P < 0.01). The overall NNE was similar for skin cancer clinic doctors (1.9; 95% CI, 1.8%-2.1%) and GPs (2.1; 95% CI, 1.9%-2.3%). This did not change after adjusting for years of clinical experience. CONCLUSIONS: GPs and skin cancer clinic doctors in Queensland treat large numbers of skin cancers and diagnose these with overall high sensitivity. The two groups diagnosed skin cancer with similar accuracy.     

Achieving a patient-centred consultation by giving feedback in its early phases

The traditional medical consultation comprises history, examination, and investigations, followed by explanation to the patient of diagnosis and management. In the course of studying a series of tape-recorded consultations in a specialist medical clinic for chronic fatigue, we have observed a different structure. In some consultations, those categorised as more `patient-centred'', doctors introduced explanation and education into the early history-taking stage. This strategy is contrasted with the traditional approach, where the doctor only elicits information during the history, and gives an explanation later. The `early feedback'' strategy may result in patients with chronic illnesses achieving greater understanding of their symptoms. We discuss the implication of these findings for medical training.     

Timer: a new objective measure of consultation content and its application to computer assisted consultations

As part of the research into the effect in the consultation of the use of a computer to prompt opportunistic preventive care a valid, objective, and practical measure of the consultation process was required. After a review of the alternative methods the Time Interval Medical Event Recorder (Timer) was developed, its reliability tested, and applied to 93 control consultations and 49 computer assisted consultations. Timer records, every five seconds, four consultation events: the problems being dealt with, the physical activity, the verbal activity, and the secondary tasks being attempted. Timer showed that control consultations lasted an average of 6 minutes 58 seconds. The doctors spent 35% of their time on administration, and patients and doctors were both conversational for just 33% of the consultation. Giving information was the most common verbal activity (48% of the duration of the consultation) with silence accounting for 21% of the time. When the computer was used the average consultation was longer, at 7 minutes and 46 seconds. The doctor's contribution to the consultation appeared to have increased. Patient centred speech fell from 36% in controls to 28% of the duration of the consultation when the computer was used, while doctor centred speech rose from 30% to 34.5%. Secondary tasks (exploring patient concepts, education, management sharing, and prevention) were attempted during 28% of the control consultations and 40% of the computer consultations. This was accounted for by the increase in prevention (p less than 0.001). Timer is a reliable and practical tool for researching the consultation, and though it has shown validity in detecting differences between consultations that use a computer and those that do not, further applications are required to establish its full value.     

新型冠状病毒肺炎疫情下基层医生自我角色定位与专家建议一致性及影响因素研究

背景　2019年底暴发了新型冠状病毒肺炎（COVID-19）疫情,基层医生作为基层疫情防控人员,其自我角色定位影响其对工作责任的认知,因此,了解基层医生角色定位及其影响因素十分必要。目的　了解COVID-19疫情下基层医生自我角色定位与专家建议的一致性,为开展基层医生针对性培训、明确重大公共卫生事件下角色定位提供依据。方法　2020年2月21-27日,通过问卷调查了解浙江省11个地级市的1 758名基层医生COVID-19疫情下自我角色定位情况,包括是否应该进行传染性疾病的健康教育、确诊COVID-19并分型、上报及转诊疑似病例、治疗疑似或确诊病例、随访经过治疗的患者5个内容的角色定位,并与专家建议的疫情下基层医生角色定位比较,与专家建议一致率≥90%为一致率高。采用多因素Logistic回归分析基层医生自我角色定位与专家建议不一致的影响因素。结果　1 758名基层医生中,1 513名（86.1%）基层医生参与一线抗疫,疫情下基层医生在参与传染病健康教育、上报或转诊疑似病例、随访经过治疗的患者的角色定位上与专家建议一致率高,分别是99.6%（1 751/1 758）、96.8%（1 702/1 758）、91.3%（1 605/1 758）。但在确诊COVID-19并分型、治疗疑似病例的基层医生角色定位上,与专家建议一致率低,分别是49.5%（871/1 758）和61.4%（1 080/1 758）。Logistic回归分析结果显示,在确诊COVID-19并分型的角色定位上,工作在村卫生室或社区卫生服务站、中高级职称的基层医生在自我角色定位上更易与专家建议相一致（P<0.05）;在治疗疑似病例的角色定位上,工作在村卫生室或社区卫生服务站、中高级职称、参与一线抗疫的基层医生在自我角色定位上更易与专家建议相一致（P<0.05）。结论　疫情下,多数基层医生参与一线抗疫,基层医生在确诊COVID-19并分型和治疗疑似病例的角色定位上与专家建议一致率低,建议疫情下要针对低职称、社区服务中心或卫生院的非一线基层医生进行诊断及治疗上的功能支持和角色定位指导。     

The Victorian Doctors Health Program: the first 3 years

The Victorian Doctors Health Program (VDHP) was established in November 2000 to provide a confidential and compassionate service for doctors and medical students with health concerns, including alcohol, other drug and mental health problems. Although funded by the Medical Practitioners Board of Victoria, the VDHP is completely independent of the Board. Its staff include a director with experience of North American Physician Health Programs and a case manager/psychologist. In its first 3 years of operation, the VDHP had 438 contacts: 218 requests for advice and information, and 220 contacts resulting in provision of services (to 92 doctors and students with alcohol or other drug problems, 82 with psychiatric problems, and 40 with stress-related or emotional problems). 99 participants received standard care (assessment, referral and up to two consultations with the program) and 56 extended care (three or more consultations with the program). 65 participants (most with substance use disorder) entered the more intensive Case Management, Aftercare and Monitoring Program (CAMP); 57 of these have had outcomes considered satisfactory, with 50 returned to work.     

Development of an Automated Healthcare Kiosk for the Management of Chronic Disease Patients in the Primary Care Setting

An increase in the prevalence of chronic disease has led to a rise in the demand for primary healthcare services in many developed countries. Healthcare technology tools may provide the leverage to alleviate the shortage of primary care providers. Here we describe the development and usage of an automated healthcare kiosk for the management of patients with stable chronic disease in the primary care setting. One-hundred patients with stable chronic disease were recruited from a primary care clinic. They used a kiosk in place of doctors’ consultations for two subsequent follow-up visits. Patient and physician satisfaction with kiosk usage were measured on a Likert scale. Kiosk blood pressure measurements and triage decisions were validated and optimized. Patients were assessed if they could use the kiosk independently. Patients and physicians were satisfied with all areas of kiosk usage. Kiosk triage decisions were accurate by the 2nd month of the study. Blood pressure measurements by the kiosk were equivalent to that taken by a nurse (p = 0.30, 0.14). Independent kiosk usage depended on patients’ language skills and educational levels. Healthcare kiosks represent an alternative way to manage patients with stable chronic disease. They have the potential to replace physician visits and improve access to primary healthcare. Patients welcome the use of healthcare technology tools, including those with limited literacy and education. Optimization of environmental and patient factors may be required prior to the implementation of kiosk-based technology in the healthcare setting.     

List size and patient contact in general medical practice

One hundred and ninety nine general practitioners collected data on consultations with patients for a representative sample of recording days. The number of consultations and amount of time spent in patient contact were positively correlated with the number of registered patients (list size), whereas the consultation rate and the amount of time spent with each patient were negatively correlated. These relations, however, were not too strong, and there was considerable variation among doctors, particularly for those with lower list sizes. These findings have implications for issues concerning quality of care and the potential effects of reductions in patient list size.     

Primary care doctors' perceptions towards evidence-based medicine in Melaka State: a questionnaire study

A cross sectional study using a self-administered questionnaire to determine the perceptions of primary care doctors towards evidence-based medicine (EBM) was conclucted in Melaka state. About 78% of the primary care doctors were aware of EBM and agreed it could improve patient care. Only 6.7% of them had ever conducted a Medline literature search. They had a low level of awareness of review publications and databases relevant to EBM; only about 33% of them were aware of the Cochrane Database of Systemic Reviews. Over half of the respondents had at least some understanding of the technical terms used in EBM. Ninety percent of the respondents had Internet access and the majority of them used it at home. The main barriers to practicing EBM were lack of personal time and lack of Internet access in the primary care clinics.     

Patients' evaluation of outpatient medical care

150 patients attending an outpatient clinic at the University of Oklahoma Hospital over a 5-week period were asked whether the clinic care they were receiving was better than, as good as, or worse than the care they had received from local physicians. The patients were drawn from the general medicine, cardiology, and oncology-hematology units and tended to be elderly and chronically ill. Most of the patients viewed favorably the care they received in the medical outpatient clinics. 65% reported they had experienced pain or discomfort in the week prior to their visit, but there was no association between these factors and degree of satisfaction with clinic care. Patients averaged about 30 minutes with the physician, and 80% felt the doctor adequately explained their medical condition to them. Patients who rated the clinic care as being worse than the care of private practitioners felt that their condition was not adequately explained. When asked to define a "good doctor," patient responses were "interest in the patient," "skilled and thorough," and "explains things to you." Characteristics identified as being most important in a "good clinic" were; good doctors, well-trained staff, and information from doctors. Of all the factors examined, the one associated most directly with patient satisfaction was personal interest on the part of the physician in the patients.