Contextual factors in clinical decision making: national survey of Canadian family physicians (original) (raw)
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How Do Contexts Affect Physicians' Clinical Reasoning? A Narrative Review
MedEdPublish
Background Research about clinical reasoning has tended to focus on the individual, assessing their ability to perform clinical reasoning tasks. However, recent studies have noted that clinical reasoning varies with the clinical context. Objectives The purpose of this narrative review is to examine how the context can affect physicians clinical reasoning skills. Methods A narrative literature review was conducted by searching PubMed, PsycINFO and Embase via Ovid using the search terms clinical OR critical AND thinking OR judgement OR reasoning. Of 22,296 results found, 25 studies were found to be relevant to our review. Results Most studies focused on diagnostic skills. Contexts affecting clinical reasoning fell into three broad categories: patient, physician and environmental (the physical and social setting) factors. Patient contexts researched included factors both personal to the patient and their physical disease manifestations. Physician contexts included experience, age, exposure to similar diagnoses, incorrect diagnostic suggestion, emotions, and the use of reflection and checklists. Environmental contexts included time pressure, unfamiliarity with surroundings, dealing with uncertainty and high-stakes outcomes. The effect of applying more than one contextual factor increasing cognitive load, was explored.
Reasoning, evidence, and clinical decision-making: The great debate moves forward
Journal of evaluation in clinical practice, 2017
When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human ...
LSE Impact Blog
How can different knowledge components, such as scientific evidence, clinical expertise, and patient preference, within the evidence-based medicine (EBM) framework be combined? Do trustworthy decisions fall out as clear-cut conclusions as part of an algorithm when an EBM approach is used? Eivind Engebretsen, Nina Køpke Vøllestad, Astrid Klopstad Wahl, Hilde Stendal Robinson and Kristin Heggen use the four stages of knowing presented by Bernhard Lonergan to show that interpretation is a central feature of EBM when combining the three components of the EBM model to reach a clinical decision.
Evidence-based medicine in primary care: qualitative study of family physicians
BMC family practice, 2003
The objectives of this study were: a) to examine physician attitudes to and experience of the practice of evidence-based medicine (EBM) in primary care; b) to investigate the influence of patient preferences on clinical decision-making; and c) to explore the role of intuition in family practice.
The illusion of evidence-based medicine: an argument for clinical judgment and patients' autonomy
RCTs exploit stable capacity theory and Mill's difference method to claim that results on test patients are generalisable to a different set of target patients. Does efficacy necessarily imply effectiveness? I argue that RCTs are more descriptive and less predictive than EBM wants them to be. Internal validity does not logically entail external validity (Cartwright, 2011). What cannot be generalised in clinical practice? Mine is not an ethical objection to RCTs whereas a purely philosophical one. If we accept the definition of health lato sensu as physical, social and psychical well-being, the highest degree of effectiveness of clinical practice is achieved by considering patients individually in their specificity (Hampton, 2002). I argue that patients' autonomy and self-determination are undermined by EBM's decision to apply RCTs' results indiscriminately. Instead of receiving the treatment that is best on paper, patients should be granted the right to a role in medical decisions. This, not for moral principles but for better medical outcomes.
BMC family practice, 2003
Evidence-based medicine is gaining prominence in primary care. This study sought to examine the relationships among family physicians' attitudes toward EBM, contextual factors, and clinical decision-making and to investigate the factors that contribute to 'contrary to evidence' clinical decisions. A postal survey mailed to a random sample of Canadian family physicians, stratified by age, gender, and practice setting. The main outcome measures were respondents' attitudes toward evidence-based medicine and preferred treatment option in four simulated clinical scenarios with wording randomly varied. Canadian family physicians report positive attitudes toward EBM, believe that EBM improves patient care, and agree that research findings are useful in the day-to-day management of patients. The scenario study showed that physicians were strongly influenced by a patient demanding/requesting either a screening test (adjusted Odds Ratio [OR] 5.15, 95% confidence interval [CI] ...
Non-clinical influences on clinical decision-making: a major challenge to evidence-based practice
JRSM, 2010
This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.
Clinical decision-making: Patients' preferences and experiences
Patient education and counseling, 2007
Objective: To determine the congruence between patients' preferred style of clinical decision-making and the style they usually experienced and whether this congruence was associated with socio-economic status and/or the perceived quality of care provided by the respondent's regular doctor. Methods: Cross-sectional survey of the American public using computer-assisted telephone interviewing. Results: Three thousand two hundred and nine interviews were completed (completion rate 72%). Sixty-two percent of respondents preferred shared decision-making, 28% preferred consumerism and 9% preferred paternalism. Seventy percent experienced their preferred style of clinical decision-making. Experiencing the preferred style was associated with high income (OR, 1.59; 95% CI, 1.16-2.16) and having a regular doctor who was perceived as providing excellent or very good care (OR, 2.39; 95% CI, 1.83-3.11). Conclusion: Both socio-economic status and having a regular doctor whom the respondent rated highly are independently associated with patients experiencing their preferred style of clinical decision-making. Practice implications: Systems which promote continuity of care and the development of an on-going doctor-patient relationship may promote equity in health care, by helping patients experience their preferred style of clinical decision-making. #