Barriers and decisions when answering clinical questions at the point of care: a grounded theory study

Abstract

Importance: Answering clinical questions affects patient-care decisions and is important to continuous professional development. The process of point-of-care learning is incompletely understood.

Objective: To understand what barriers and enabling factors influence physician point-of-care learning and what decisions physicians face during this process.

Design: Focus groups with grounded theory analysis. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify barriers, enabling factors, and key decisions related to physician information-seeking activities.

Setting: Academic medical center and outlying community sites.

Participants: Purposive sample of 50 primary care and subspecialist internal medicine and family medicine physicians, interviewed in 11 focus groups.

Results: Insufficient time was the main barrier to point-of-care learning. Other barriers included the patient comorbidities and contexts, the volume of available information, not knowing which resource to search, doubt that the search would yield an answer, difficulty remembering questions for later study, and inconvenient access to computers. Key decisions were whether to search (reasons to search included infrequently seen conditions, practice updates, complex questions, and patient education), when to search (before, during, or after the clinical encounter), where to search (with the patient present or in a separate room), what type of resource to use (colleague or computer), what specific resource to use (influenced first by efficiency and second by credibility), and when to stop. Participants noted that key features of efficiency (completeness, brevity, and searchability) are often in conflict.

Conclusions and relevance: Physicians perceive that insufficient time is the greatest barrier to point-of-care learning, and efficiency is the most important determinant in selecting an information source. Designing knowledge resources and systems to target key decisions may improve learning and patient care.