How do doctors use information in real-time? A qualitative study of internal medicine resident precepting

Background  Despite the importance of evidence-based medicine in medical education, little observational research exists on how doctors-in-training seek and use evidence from information resources in ambulatory care. Objective  To describe information exchange behaviour by internal medicine residents and attendings in ambulatory resident clinic precepting rooms. Design  We observed resident behaviour and audiotaped resident–attending doctor interactions during precepting sessions. Participants  Participating residents included 70 of an eligible 89 residents and 28 of 34 eligible attendings from one large academic internal medicine residency programme in the Midwestern USA. Residents were observed during 95 separate precepting interactions at four ambulatory sites. Approach  Using a qualitative approach, we analysed transcripts and field notes of observed behaviours and interactions looking for themes of information exchange. Coders discussed themes which were refined using feedback from an interdisciplinary panel. Results  Four themes of information exchange behaviour emerged: (i) questioning behaviours that were used as part of the communication process in which the resident and attending doctor could reason together; (ii) searching behaviour of non-human knowledge sources occurred in a minority of precepting interations; (iii) unsolicited knowledge offering and (iv) answering behaviours were important means of exchanging information. Conclusions  Most clinic interactions between resident and attending doctors relied heavily on spoken deliberation without resorting to the scientific literature or other published information resources. These observations suggest a range of factors that may moderate information exchange behaviour in the precepting context including relationships, space and efficiency. Future research should aim to more readily adapt information resources to the relationships and practice context of precepting.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72879/1/j.1365-2753.2006.00752.x.pd

Do we practice what we preach? A qualitative assessment of resident–preceptor interactions for adherence to evidence‐based practice

Background  Evidence‐based medicine (EBM) is important in training doctors for high‐quality care. Yet little is known about whether ambulatory precepting incorporates the concepts and principles of EBM. Methods  The authors observed and audiotaped 95 internal medicine residency precepting interactions and rated interactions using a qualitative analytic template consisting of three criteria: (1) presence of clinical questions; (2) presence of an evidence‐based process; and (3) resident ability to articulate a clinical question. Results  Sixty‐seven of 95 audio tapes (71%) were of acceptable quality to allow template analysis. Thirty (45%) contained explicit clinical questions; 11 (16%) included an evidence‐based process. Resident ability to articulate a clinical question when prompted was rated as at least ‘fair’ in 59 of 67 interactions (88%). Conclusions  EBM was not optimally implemented in these clinics. Future research could explore more systematically what factors facilitate or impair the use of EBM in the real‐time ambulatory training context.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99027/1/j.1365-2753.2008.00966.x.pd

Data from: Shared decision-making as a cost-containment strategy: US physician reactions from a cross-sectional survey

Objective: To assess US physicians’ attitudes towards using shared decision-making (SDM) to achieve cost containment. Design: Cross-sectional mailed survey. Setting: US medical practice. Participants: 3897 physicians were randomly selected from the AMA Physician Masterfile. Of these, 2556 completed the survey. Main outcome measures: Level of enthusiasm for “Promoting better conversations with patients as a means of lowering healthcare costs”; degree of agreement with “Decision support tools that show costs would be helpful in my practice” and agreement with “should promoting SDM be legislated to control overall healthcare costs”. Results: Of 2556 respondents (response rate (RR) 65%), two-thirds (67%) were ‘very enthusiastic’ about promoting SDM as a means of reducing healthcare costs. Most (70%) agreed decision support tools that show costs would be helpful in their practice, but only 24% agreed with legislating SDM to control costs. Compared with physicians with billing-only compensation, respondents with salary compensation were more likely to strongly agree that decision support tools showing costs would be helpful (OR 1.4; 95% CI 1.1 to 1.7). Primary care physicians (vs surgeons, OR 1.4; 95% CI 1.0 to 1.6) expressed more enthusiasm for SDM being legislated as a means to address healthcare costs. Conclusions: Most US physicians express enthusiasm about using SDM to help contain costs. They believe decision support tools that show costs would be useful. Few agree that SDM should be legislated as a means to control healthcare costs

Views of US physicians about controlling health care costs

Physicians' views about health care costs are germane to pending policy reforms

Insurance Benefit Preferences of the Low-income Uninsured

A frequently cited obstacle to universal insurance is the lack of consensus about what benefits to offer in an affordable insurance package. This study was conducted to assess the feasibility of providing uninsured patients the opportunity to define their own benefit package within cost constraints. DESIGN: Structured group exercises SETTING: Community setting PARTICIPANTS: Uninsured individuals recruited from clinical and community settings in central North Carolina. MEASUREMENTS: Insurance choices were measured using a simulation exercise, CHAT (Choosing Healthplans All Together). Participants designed managed care plans, individually and as groups, by selecting from 15 service categories having varied levels of restriction (e.g., formulary, copayments) within the constraints of a fixed monthly premium comparable to the typical per member/per month managed care premium paid by U.S. employers. MAIN RESULTS: Two hundred thirty-four individuals who were predominantly male (70%), African American (55%), and socioeconomically disadvantaged (53% earned <$15,000 annually) participated in 22 groups and were able to design health benefit packages individually and in groups. All 22 groups chose to cover hospitalization, pharmacy, dental, and specialty care, and 21 groups chose primary care and mental health. Although individuals' choices differed from their groups' selections, 86% of participants were willing to abide by group choices. CONCLUSIONS: Groups of low-income uninsured individuals are able to identify acceptable benefit packages that are comparable in cost but differ in benefit design from managed care contracts offered to many U.S. employees today.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72645/1/j.1525-1497.2002.10609.x.pd