Family Practice, 2015, Vol. 32, No. 5, 533–537 doi:10.1093/fampra/cmv046 Advance Access publication 18 June 2015
Health Service Research
General practice trainees’ information searching strategies for clinical queries encountered in daily practice Downloaded from http://fampra.oxfordjournals.org/ at Florida International University on November 14, 2015
Marlous F Kortekaas*, Marie-Louise E L Bartelink, Lia Boelman, Arno W Hoes and Niek J de Wit Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands. *Correspondence to Marlous F Kortekaas, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, STR 6.131, PO Box 85500, 3508 GA, Utrecht, The Netherlands; E-mail: [email protected]
Abstract Background. Earlier studies have shown that clinical queries are common among doctors. Data on the information-seeking behaviour of general practice (GP) trainees are scarce though, and numbers studied are small. Objective. The objective of this study was to determine how often and how GP trainees search for answers to clinical queries encountered in daily clinical practice. Methods. Third-year GP trainees kept logs on all patient contacts for eight consecutive practice days. Information was obtained on patient contacts (description), clinical queries (frequency, type), seeking behaviour (frequency, moment, reason not to search, resources used, duration of search) and answers (frequency, impact). Descriptive analyses were performed; frequencies and percentages were computed. We calculated the number of clinical queries per patient, the number of searches per query and the number of answers per search. Results. Seventy-six trainees reported 1533 clinical queries about 7300 patients presenting 7619 complaints [mean of 0.2 queries per patient, standard deviation (SD) 0.1]. For most of the queries trainees pursued an answer (mean of 0.8 per query, SD 0.2), mostly during consultation (61% of searches), and frequently retrieved answers (mean of 0.8 per search, SD 0.17) they reported to improve clinical decision making in 26%. Most common resources were colleagues or supervisors (28%), and national GP guidelines (26%). The median duration of a search was 4 minutes (interquartile range 3). Conclusion. GP trainees have one clinical query per five patients. They often attempted to find answers and reported to succeed in most of the searches, primarily by consulting supervisors or colleagues and national GP guidelines. Key words: Family practice, general practice, information-seeking behaviour, primary health care, trainee.
Introduction General practice (GP) trainees in the Netherlands learn to work according to the principles of evidence-based medicine (EBM). EBM aims at integrating clinical expertize, patient values and the best available clinical evidence in daily clinical practice (1). EBM is taught according to the five steps as stated in the Sicily Statement: ask, acquire, appraise, apply and assess (2). An essential skill that
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
trainees learn during their EBM training is to search for evidencebased answers to the clinical queries that they encounter in daily clinical practice. Trainees are reported to have many clinical queries, 0.7–1.6 clinical queries per patient (3–6). There are different ways to deal with queries, and different ways to search for answers. The evidence required to answer queries can be ranked based on the quality of the available evidence in the so-called
533
Family Practice, 2015, Vol. 32, No. 5
534 EBM pyramid (7). According to the described hierarchy of information resources for evidence, GP trainees can use (i) guidelines/preappraised resources, (ii) unfiltered information sources and/or (iii) expert opinion or background information. To optimize EBM training, information on what type of clinical queries GP trainees have, and how often and how they try to pursue answers would be instrumental. The objective of this study is to determine the seeking behaviour of GP trainees, by assessing how often and how they search for answers to clinical queries they encounter in daily clinical practice.
Table 1. Seeking behaviour in third-year GP trainees (N = 76) from the GP vocational training program in Utrecht, in 2011 (data collected from logs) Item
Variables
Patient contact information
Sex
Methods Design
Setting Our study was performed within the GP vocational training program of the University Medical Centre Utrecht, the Netherlands, in 2011.
Clinical query
Seeking behaviour
Answer to the clinical query
Resource (attending GP/colleague, national GP guideline, other guideline(s), textbook, consultation of a specialist, pharmacotherapeutic guideline, PubMed, pre-appraised bibliographic databases and other) Impact, according to trainee (improvement of clinical decision makingb, confirmation of the decision, expanding knowledge, recall of knowledge, reassurance, none and other)
Study population All third-year GP trainees who participated in the GP vocational training program (n = 82) were included when they entered their final year of training. Demographics and baseline characteristics of all participants were collected.
Data collection Trainees were asked to keep logs on all patient consultations during eight consecutive practice days. Telephone contacts with patients were not reported. Data were collected using a paper or digital log, depending on the trainee’s preference. In Table 1 is shown what data were collected on (i) patient contact information, (ii) clinical queries, (iii) seeking behaviour and (iv) answers. A clinical query was defined as every patient-related question that was a reason to search for an answer. Seeking behaviour was defined as searching for an answer to a clinical query using all possible human or written information resources. Human resources pertained GP trainers, colleagues or specialists. Written resources pertained textbooks, guidelines (national GP and other guidelines), PubMed and pre-appraised bibliographic databases (such as Clinical Evidence, TRIP, Cochrane). All written resources but textbooks were considered evidence based, as textbooks could be out-dated. Trainees were allowed to report more than one complaint per patient contact, and more queries in each consultation. In paper logs, trainees could report if they used more than one resource, and this was categorized as ‘multiple resources’. Trainees reported what impact they thought the retrieved information had on their clinical management decision. As shown in Table 1, all questions about ‘seeking behaviour’ and ‘answers to clinical queries’ were multiple-choice questions containing an option ‘other’. Trainees were allowed to report more than one complaint per patient contact and more queries in each consultation. At baseline, all trainees were asked
a Pragmatic approach: based on their clinical management on the available information at that moment. b According to the trainee.
to self-assess their EBM knowledge and EBM attitude on a five-point Likert scale ranging from very poor to very good.
Data analysis Data were recorded in SPSS version 20.0. Presented complaints were classified according to the International Classification of Health Problems of Primary Care (ICPC) by the researchers (11). Frequencies and percentages of the categorical variables were computed. For all normally distributed continuous variables, means and standard deviations (SD) were calculated. For non-normally distributed continuous data, medians and interquartile ranges (IQR) were calculated. Seeking behaviour characteristics were calculated as (i) number of clinical queries as a proportion of all patient contacts, (ii) number of performed searches as a proportion of all queries and (iii) number of retrieved answers as a proportion of all performed searches.
Ethics This study design was assessed by the UMC Utrecht Ethics Committee and regarded as non-eligible for full informed consent.
Downloaded from http://fampra.oxfordjournals.org/ at Florida International University on November 14, 2015
We used baseline data from the PINET study (Personalized INtegrated Evidence-based medicine teaching for Trainees in GP), a prospective, cluster randomized controlled trial, in which third-year GP trainees were allocated to either an integrated EBM training program or a standalone (i.e. the regular) training program for trainees and their supervisors. The primary outcome of the PINET study was EBM behaviour of GP trainees in terms of (i) seeking behaviour (8) and (ii) adherence to the practice guidelines of the Dutch College of General Practice (9). Secondary outcomes were knowledge of and attitude towards EBM (10).
Age Anonymous description of the patient contact, as recorded in the Electronic Medical Recording system (anamnesis, physical examination, consult evaluation and plan) Reason for encounter (ICPC code) (11) Presence of clinical query (yes/no) Written description Type of question (diagnosis, aetiology, prognosis, therapy) Presence of seeking behaviour (yes/no) Duration of search (minutes) If yes: search moment (before patient consultation, during patient consultation, directly after patient consultation, later on the same day, at home and other) If no: reason (little relevance of clinical question, lack of time, pragmatic approacha and other) Answer retrieved (yes/no)
How do GP trainees search for answers to patient-based queries? However, we obtained informed consent from the participants for the use of the data from questionnaires, tests and logs. All trainees reported patient-related data in such a way that these could not be related to individual patients (thus, no name, address etc. were reported).
Results Study population
Patients Seventy-six trainees reported data on 7300 patient contacts with 7619 different reasons for encounter as collected on 4–10 practice days per trainee (mean of 7.4 practice days, SD 1.2). Trainees encountered on average a total of 96 patients (SD 23, a mean of 13 patients per day [SD 3]). Most frequent reasons for encounter of the patients were skin (ICPC category S, 19%), musculoskeletal (L, 18%) or respiratory complaints (R, 17%). Least frequent reasons for encounter of the patients included ‘haematologic and lymphatic system’ (B,
Health Service Research
General practice trainees’ information searching strategies for clinical queries encountered in daily practice Downloaded from http://fampra.oxfordjournals.org/ at Florida International University on November 14, 2015
Marlous F Kortekaas*, Marie-Louise E L Bartelink, Lia Boelman, Arno W Hoes and Niek J de Wit Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands. *Correspondence to Marlous F Kortekaas, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, STR 6.131, PO Box 85500, 3508 GA, Utrecht, The Netherlands; E-mail: [email protected]
Abstract Background. Earlier studies have shown that clinical queries are common among doctors. Data on the information-seeking behaviour of general practice (GP) trainees are scarce though, and numbers studied are small. Objective. The objective of this study was to determine how often and how GP trainees search for answers to clinical queries encountered in daily clinical practice. Methods. Third-year GP trainees kept logs on all patient contacts for eight consecutive practice days. Information was obtained on patient contacts (description), clinical queries (frequency, type), seeking behaviour (frequency, moment, reason not to search, resources used, duration of search) and answers (frequency, impact). Descriptive analyses were performed; frequencies and percentages were computed. We calculated the number of clinical queries per patient, the number of searches per query and the number of answers per search. Results. Seventy-six trainees reported 1533 clinical queries about 7300 patients presenting 7619 complaints [mean of 0.2 queries per patient, standard deviation (SD) 0.1]. For most of the queries trainees pursued an answer (mean of 0.8 per query, SD 0.2), mostly during consultation (61% of searches), and frequently retrieved answers (mean of 0.8 per search, SD 0.17) they reported to improve clinical decision making in 26%. Most common resources were colleagues or supervisors (28%), and national GP guidelines (26%). The median duration of a search was 4 minutes (interquartile range 3). Conclusion. GP trainees have one clinical query per five patients. They often attempted to find answers and reported to succeed in most of the searches, primarily by consulting supervisors or colleagues and national GP guidelines. Key words: Family practice, general practice, information-seeking behaviour, primary health care, trainee.
Introduction General practice (GP) trainees in the Netherlands learn to work according to the principles of evidence-based medicine (EBM). EBM aims at integrating clinical expertize, patient values and the best available clinical evidence in daily clinical practice (1). EBM is taught according to the five steps as stated in the Sicily Statement: ask, acquire, appraise, apply and assess (2). An essential skill that
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
trainees learn during their EBM training is to search for evidencebased answers to the clinical queries that they encounter in daily clinical practice. Trainees are reported to have many clinical queries, 0.7–1.6 clinical queries per patient (3–6). There are different ways to deal with queries, and different ways to search for answers. The evidence required to answer queries can be ranked based on the quality of the available evidence in the so-called
533
Family Practice, 2015, Vol. 32, No. 5
534 EBM pyramid (7). According to the described hierarchy of information resources for evidence, GP trainees can use (i) guidelines/preappraised resources, (ii) unfiltered information sources and/or (iii) expert opinion or background information. To optimize EBM training, information on what type of clinical queries GP trainees have, and how often and how they try to pursue answers would be instrumental. The objective of this study is to determine the seeking behaviour of GP trainees, by assessing how often and how they search for answers to clinical queries they encounter in daily clinical practice.
Table 1. Seeking behaviour in third-year GP trainees (N = 76) from the GP vocational training program in Utrecht, in 2011 (data collected from logs) Item
Variables
Patient contact information
Sex
Methods Design
Setting Our study was performed within the GP vocational training program of the University Medical Centre Utrecht, the Netherlands, in 2011.
Clinical query
Seeking behaviour
Answer to the clinical query
Resource (attending GP/colleague, national GP guideline, other guideline(s), textbook, consultation of a specialist, pharmacotherapeutic guideline, PubMed, pre-appraised bibliographic databases and other) Impact, according to trainee (improvement of clinical decision makingb, confirmation of the decision, expanding knowledge, recall of knowledge, reassurance, none and other)
Study population All third-year GP trainees who participated in the GP vocational training program (n = 82) were included when they entered their final year of training. Demographics and baseline characteristics of all participants were collected.
Data collection Trainees were asked to keep logs on all patient consultations during eight consecutive practice days. Telephone contacts with patients were not reported. Data were collected using a paper or digital log, depending on the trainee’s preference. In Table 1 is shown what data were collected on (i) patient contact information, (ii) clinical queries, (iii) seeking behaviour and (iv) answers. A clinical query was defined as every patient-related question that was a reason to search for an answer. Seeking behaviour was defined as searching for an answer to a clinical query using all possible human or written information resources. Human resources pertained GP trainers, colleagues or specialists. Written resources pertained textbooks, guidelines (national GP and other guidelines), PubMed and pre-appraised bibliographic databases (such as Clinical Evidence, TRIP, Cochrane). All written resources but textbooks were considered evidence based, as textbooks could be out-dated. Trainees were allowed to report more than one complaint per patient contact, and more queries in each consultation. In paper logs, trainees could report if they used more than one resource, and this was categorized as ‘multiple resources’. Trainees reported what impact they thought the retrieved information had on their clinical management decision. As shown in Table 1, all questions about ‘seeking behaviour’ and ‘answers to clinical queries’ were multiple-choice questions containing an option ‘other’. Trainees were allowed to report more than one complaint per patient contact and more queries in each consultation. At baseline, all trainees were asked
a Pragmatic approach: based on their clinical management on the available information at that moment. b According to the trainee.
to self-assess their EBM knowledge and EBM attitude on a five-point Likert scale ranging from very poor to very good.
Data analysis Data were recorded in SPSS version 20.0. Presented complaints were classified according to the International Classification of Health Problems of Primary Care (ICPC) by the researchers (11). Frequencies and percentages of the categorical variables were computed. For all normally distributed continuous variables, means and standard deviations (SD) were calculated. For non-normally distributed continuous data, medians and interquartile ranges (IQR) were calculated. Seeking behaviour characteristics were calculated as (i) number of clinical queries as a proportion of all patient contacts, (ii) number of performed searches as a proportion of all queries and (iii) number of retrieved answers as a proportion of all performed searches.
Ethics This study design was assessed by the UMC Utrecht Ethics Committee and regarded as non-eligible for full informed consent.
Downloaded from http://fampra.oxfordjournals.org/ at Florida International University on November 14, 2015
We used baseline data from the PINET study (Personalized INtegrated Evidence-based medicine teaching for Trainees in GP), a prospective, cluster randomized controlled trial, in which third-year GP trainees were allocated to either an integrated EBM training program or a standalone (i.e. the regular) training program for trainees and their supervisors. The primary outcome of the PINET study was EBM behaviour of GP trainees in terms of (i) seeking behaviour (8) and (ii) adherence to the practice guidelines of the Dutch College of General Practice (9). Secondary outcomes were knowledge of and attitude towards EBM (10).
Age Anonymous description of the patient contact, as recorded in the Electronic Medical Recording system (anamnesis, physical examination, consult evaluation and plan) Reason for encounter (ICPC code) (11) Presence of clinical query (yes/no) Written description Type of question (diagnosis, aetiology, prognosis, therapy) Presence of seeking behaviour (yes/no) Duration of search (minutes) If yes: search moment (before patient consultation, during patient consultation, directly after patient consultation, later on the same day, at home and other) If no: reason (little relevance of clinical question, lack of time, pragmatic approacha and other) Answer retrieved (yes/no)
How do GP trainees search for answers to patient-based queries? However, we obtained informed consent from the participants for the use of the data from questionnaires, tests and logs. All trainees reported patient-related data in such a way that these could not be related to individual patients (thus, no name, address etc. were reported).
Results Study population
Patients Seventy-six trainees reported data on 7300 patient contacts with 7619 different reasons for encounter as collected on 4–10 practice days per trainee (mean of 7.4 practice days, SD 1.2). Trainees encountered on average a total of 96 patients (SD 23, a mean of 13 patients per day [SD 3]). Most frequent reasons for encounter of the patients were skin (ICPC category S, 19%), musculoskeletal (L, 18%) or respiratory complaints (R, 17%). Least frequent reasons for encounter of the patients included ‘haematologic and lymphatic system’ (B,
