Since the 1980s, studies have shown that clinicians frequently raise questions during patient encounters in all healthcare settings. These studies have suggested that although questions arise frequently, they often go unanswered. “Unanswered questions should be seen as an opportunity to improve outcomes by filling gaps in medical knowledge,” says Guilherme Del Fiol, MD, PhD. He adds that understanding clinicians’ questions is essential to guiding the design of interventions that aim to provide the right information at the right time.

According to Dr. Del Fiol, there are challenges associated with maintaining current knowledge in medicine. “Several factors can come into play,” he says. “Science is continuing to expand medical knowledge, but this can make it increasingly complex to appropriately deliver healthcare. In addition, the aging population continues to grow, a phenomenon that further complicates how easily clinicians can address more difficult questions at the point of care.” No systematic reviews have been available on the clinical questions raised by clinicians in the context of patient care and decision making.

A Systematic Review on Clinical Questions

Dr. Del Fiol and colleagues recently conducted a systematic review of the literature on clinicians’ questions. Published in JAMA Internal Medicine, the research focused on the need for general medical knowledge that could be obtained from books, journals, specialists, and online resources. The systematic review took into account the frequency by which clinicians raised clinical questions, how often these questions were pursued and how often answers were successfully found, and the types of questions that were typically asked. They also sought to determine overriding themes and the potential effects of information seeking on clinicians’ decision making.

Clinical-Questions-Callout

For the analysis, Dr. Del Fiol and colleagues reviewed studies that examined questions raised and observed by clinicians in the context of patient care. Of the more than 21,000 citations that were considered, 72 met the study group’s selection criteria. The average frequency of questions raised was 0.57 per patient seen, but clinicians pursued just 51% of these questions (Table 1). However, clinicians who pursued these questions found answers to them 78% of the time. Overall, 34% of questions concerned drug treatment, and 24% concerned potential causes of symptoms, physical findings, or diagnostic test findings.

“Our results were fairly stable over time despite the broad availability of online evidence resources that can answer questions,” says Dr. Del Fiol. “Unanswered questions are missed opportunities for timely learning and practice improvement.” In addition, Dr. Del Fiol notes that clinicians’ lack of time and doubt that a useful answer exists were the main barriers to information seeking (Table 2).

Searching for Solutions With EHR

The study team was unable to determine whether decision support tools and electronic health record (EHR) systems were available to clinicians in many of the included studies. “There is some early evidence that EHR systems with clinical decision support tools and seamless access to online reference resources can help clinicians answer simple questions more quickly,” Dr. Del Fiol says. “These tools have the potential to improve patient outcomes and physician knowledge. The key is to design information interventions that allow clinicians to easily estimate the benefit of information that’s available and compare that with the cost of seeking this information as early as possible and with minimal effort.”

Important Implications on Physician Training

The findings from Dr. Del Fiol’s study team have implications for how clinicians are trained and for lifelong learning. “Interventions like continuing medical education have been initiated in order to enhance physician knowledge and performance, but these programs typically follow a passive learning approach,” Dr. Del Fiol says. “We need to find new ways to learn within the context of care. Such approaches could be integrated as a part of the requirements for clinicians to maintain certification. More importantly, they can encourage a lifelong commitment to learning with ongoing knowledge self-assessments.”

EHR systems can be of particular help to improving on clinician knowledge gaps, says Dr. Del Fiol. “EHRs are capable of identifying these knowledge gaps and encouraging clinicians to address them at the point of care. In addition, questions and answers relating to individual patients can be tracked in EHRs and made available to the entire care team. The questions that are raised in the EHR can also be used as a teaching device, with interesting questions being used in broader discussions for venues like grand rounds. Another option would be to use EHRs to automatically suggest unasked but relevant questions. These ideas are feasible to implement in current EHR systems and have the potential to provide a foundation for an innovative learning environment.”

References

Del Fiol G, Workman TE, Gorman PN. Clinical questions raised by clinicians at the point of care: a systematic review. JAMA Intern Med. 2014 Mar 24 [Epub ahead of print]. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1846630.

Davidoff F, Miglus J. Delivering clinical evidence where it’s needed: building an information system worthy of the profession. JAMA. 2011;305:1906-1907.

Ely JW, Osheroff JA, Chambliss ML, Ebell MH, Rosenbaum ME. Answering physicians’ clinical questions: obstacles and potential solutions. J Am Med Inform Assoc. 2005;12:217-224.

González-González AI, Dawes M, Sánchez-Mateos J, et al. Information needs and information-seeking behavior of primary care physicians. Ann Fam Med. 2007;5:345-352.

Ely JW, Burch RJ, Vinson DC. The information needs of family physicians: case-specific clinical questions. J Fam Pract. 1992;35:265-269.

Del Fiol G, Haug PJ, Cimino JJ, Narus SP, Norlin C, Mitchell JA. Effectiveness of topic-specific infobuttons: a randomized controlled trial. J Am Med Inform Assoc. 2008;15:752-759.

Ely JW, Osheroff JA, Gorman PN, et al. A taxonomy of generic clinical questions: classification study. BMJ. 2000;321:429-432.

Schaafsma F, Hulshof C, de Boer A, Hackmann R, Roest N, van Dijk F. Occupational physicians: what are their questions in daily practice? An observation study. Occup Med (Lond). 2006;56:191-198.

Del Fiol G, Huser V, Strasberg HR, Maviglia SM, Curtis C, Cimino JJ. Implementations of the HL7 Context-Aware Knowledge Retrieval (“Infobutton”) Standard: challenges, strengths, limitations, and uptake. J Biomed Inform. 2012;45:726-735.