BMJ No 7121 Volume 315
Information in Practice Saturday 6 December 1997
Questioning behaviour in general practice: a pragmatic study
A Richard Barrie, Alison M Ward
Abstract
Objective: To study the extent to which general practitioners' questioning behaviour in routine practice is likely to encourage the adoption of evidence based medicine.Design: Self recording of questions by doctors during consultations immediately followed by semistructured interview.
Setting: Urban Australian general practice.
Subjects: Random sample of 27 general practitioners followed over a half day of consultations.
Main outcome measures: Rate of recording of clinical questions about patients' care which doctors would like answered; frequency with which doctors found answers to their questions.
Results: Doctors asked a total of 85 clinical questions, at a rate of 2.4 for every 10 patients seen. They found satisfactory answers to 67 (79%) of these questions. Doctors who worked in small practices (of one or two doctors) had a significantly lower rate of questioning than did those in larger practices (1.6 questions per 10 patients versus 3.0 patients, P=0.049). No other factors were significantly related to rate of questioning.
Conclusions: These results do not support the view that doctors routinely generate a large number of unanswered clinical questions. It may be necessary to promote questioning behaviour in routine practice if evidence based medicine and other forms of self directed learning are to be successfully introduced.
Introduction
Evidence based medicine is a style of practice in which doctors manage problems by reference to valid and relevant information. It consists of five steps: formulating answerable questions, tracking down the best evidence to answer them, critically appraising the evidence, applying it in practice, and evaluating performance.(1) Much attention has been paid to the last four of these steps, but the first step - asking appropriate questions - has received less attention.
Current understanding of the questioning behaviour of doctors comes from research into information needs.(2-9) Most studies of information needs have identified a substantial excess of unanswered questions.(2,3)(8) However, information needs differ importantly from questioning behaviour. Information needs may be recognised or unrecognised and are independent of the doctor's behaviour - it is a normative concept. Questioning behaviour, however, is an empirical one: it is the process by which a doctor recognises the need for information. Studies focussing on information needs may therefore give an inaccurate picture of questioning behaviour.
The main aim of our study was to test the hypothesis that in routine practice doctors generate a large number of questions, many of which go unanswered. We also examined the possible influence of demographic factors on the questioning behaviour of general practitioners.
Methods
Subjects
The study population was a random sample of 35 of the 128 general
practitioners in the Central Coastal Division of General Practice in
Perth, Western Australia. We excluded general practitioners with
teaching or research contracts at the University of Western Australia
because we thought that their behaviour might differ from that of
non-academic doctors. Of the 35 doctors selected, two had left the
area, leaving an available population of 33, and 27 (82%) of these
participated fully in the study.
Study design
The doctors were initially contacted by telephone. Those who
agreed to participate were sent a letter asking them to "make a note
through one clinical session of any questions which arise regarding the
clinical care of each patient, to which you would like an answer" and
a form on which to record their questions. The form was piloted with
six members of the University Department of General Practice, which
resulted in minor changes in wording. The doctors were reminded of
their agreement to participate just before the designated session.
After the clinical session they were interviewed by ARB using a semistructured interview. They were asked which questions they had been able to answer during the session and what sources they had used. Questions that remained unanswered at the end of the session were followed up by telephone a week later to see if answers had been obtained.
The doctors were asked which sources of information they most commonly used in routine practice, and were provided with a prompt list of 10 possible sources, although responses were not confined to these. We later condensed these 10 categories to six when it became apparent that the doctors used some of the categories interchangeably. Doctors twice cited the patient as a source of information, and four times they cited themselves, answering their own questions by recall of information or a trial of management. We included these answers in the "Doctor or patient" category.
We obtained demographic information to investigate whether questioning behaviour varied with doctors' characteristics, size of practice, or workload.
We classified all questions asked into four categories: clinical, organisational, patient data, and ethical dilemmas - corresponding closely to Gorman's classification of medical information.(9) Organisational questions concerned local information such as the address of a specialist. Dilemmas included, for example, how best to respond to a request for medical examination as part of an employee's apparently dishonest claim for compensation for occupational illness. We excluded the last three categories - organisational, patient data, and ethical dilemmas - from further analysis because they are unlikely to act as a starting point for practising evidence based medicine.
Statistical analysis
To examine whether certain characteristics were associated with
higher or lower rates of questioning we divided the subjects into a
number of dichotomous groups (see table 1). We analysed the data using
spss for Windows, version 6.1.3, and used Student's
t tests to examine
differences.
Results
Table 1 shows the participating doctors' characteristics. Their average time since qualification was 19.2 years (range 12-38 years); the average number of doctors in their practices was 3.0; 44% of them were women; 44% were part time; and 63% were graduates of the University of Western Australia, the rest being from other schools in Australia (4), the United Kingdom (4), the Republic of Ireland (1), and Sri Lanka (1).
| Table 1 - Characteristics of 27 general practitioners, analysed with respect to their average rates of recording of clinical questions during patient consultations (n=85) | |
|---|---|
| Characteristic | No of questions asked per 10 patients |
| Personal and practice characteristics | |
| Sex: | |
| Men (n=15) | 2.2 |
| Women (n=12) | 2.6 |
| Working practice: | |
| Full time (n=15) | 2.1 |
| Part time (n=12) | 2.7 |
| Size of general practice: | |
| One or two doctors (n=12) | 1.6 |
| Three or more doctors (n=15) | 3.0* |
| Education and training | |
| Years since graduation: | |
| 18 and under (n=14) | 2.4 |
| 19 and over (n=13) | 2.4 |
| Medical school: | |
| University of Western Australia (n=17) | 2.2 |
| Other (n=10) | 2.7 |
| Rate and volume of work | |
| Consultation rate: | |
| <16 minutes per patient (n=14) | 2.6 |
| 16 minutes and over per patient (n=13) | 2.1 |
| No of patients seen in half day session: | |
| 14 and over (n=13) | 2.2 |
| <14 (n=14) | 2.7 | *P=0.049. |
During the study, the doctors saw 376 patients over 95.4 hours of consulting, at an average rate of 16.8 minutes per patient. A total of 119 questions were recorded: 85 were clinical, 28 were organisational, 4 were patient data questions, and 2 were ethical dilemmas. This gives an overall rate of 3.2 questions per 10 consultations. The 85 clinical questions were asked at an average rate of 2.4 every 10 consultations, and 52 (61%) were answered during the consultation. Of the 33 that were not, 15 (18%) had been satisfactorily answered at follow up a week later, leaving 18 (21%) unanswered. Of these unanswered questions, 3 had been pursued unsuccessfully and 15 had not been pursued at all. This shows that 82% of the clinical questions were followed up, 79% successfully. Doctors in small practices (one or two doctors) asked significantly fewer questions per consultation than those in larger practices (P<0.05), and no other significant differences were found (table 1).
| Table 2 - Sources of information used by 27 general practitioners to pursue answers to clinical questions during and after patients' consultations, and sources stated as most often used (15 of the 85 questions raised were not pursued by doctors) | |||||
|---|---|---|---|---|---|
| Information source | Used during consultation | Used after consultation | Total | Stated as most often used* | |
| Successfully | Unsuccessfully | ||||
| "Desk top" references† | 38 | 0 | 0 | 38 (54%) | 42% |
| Other professionals‡ | 8 | 10 | 0 | 18 (26%) | 22% |
| General practitioner colleagues | 1 | 0 | 0 | 1 (1%) | 18% |
| Textbooks | 2 | 1 | 1 | 4 (6%) | 13.5% |
| Journals | 0 | 1 | 1 | 2 (3%) | 3.5% |
| Doctor or patient | 3 | 3 | 0 | 6 (9%) | 0 |
| Medline search | 0 | 0 | 1 | 1 (1%) | 1% |
| Total | 52 (74%) | 15 (21%) | 3 (4%) | 70 | |
| *Frequency with which each was stated at interview to be among
the three most common sources of information used.
†Such as Monthly Index of Medical Specialties (MIMS), prescribers handbooks, guides on immunisation and travel. ‡Includes "Speak to a specialist" and "Refer to a specialist.". | |||||
Table 2 shows the information sources the doctors used to answer their questions. "Desk top" references and human sources were used to answer 90% of questions answered. Textbooks and journals were little used. The three information sources that the doctors said they used most often were similar to the sources they actually used in the study, with the exception that they said they used general practitioner colleagues more than they actually did. In the interviews after the consulting sessions, it became evident that most of the doctors did not feel that they had a major need for new information sources. If information was really needed it was obtainable. When asked what information sources they would like but currently do not have, six (22%) doctors stated that they wanted no new sources. Of the 11 who mentioned a computer, most did not seem to have a precise idea of how it might be helpful.
Discussion
Questioning behaviour
In this study general practitioners recorded clinical questions at
a rate of 2.4 questions every 10 consultations. This is substantially
lower than the rates of questioning reported in previous studies, most
of which have been concerned primarily with doctors' information
needs.(2,3)(5,6) In our study the doctors recorded
questions, as they arose, on a sheet of paper. There was no face to
face contact with the observer until after the questions had been
identified. Our intention was to influence routine behaviour as little
as possible.
Previous studies have used various methods to identify questions, often involving the interrogation of the doctor by the observer. Thus Covell and Gorman interviewed doctors after each consultation,(2,3) which may have acted as a stimulus to question forming. Timpka reviewed videotaped consultations with the doctor concerned,(5) and Forsythe used ethnographic observation of ward rounds in a teaching hospital to record all verbal and non-verbal questioning.(6) The rates of questions per 10 patients seen in these studies were 6.6,(2) 5.7,(3) 18.5,(5) and 57.7.(6) Ely's study of family doctors, which had a far lower rate of questioning (0.7 per 10 patients seen), counted a question only when the doctor was observed seeking information.(4)
Questioning behaviour probably varies with the clinical setting, but the rate of questioning identified in any one study may also vary substantially depending on the method used to identify questions. Smith recently reviewed this literature and concluded that "when doctors see patients they usually generate at least one question."(10) While it is clear that they could, and perhaps should, be generating questions at this rate, our study suggests that they do not actually do so.
If asking questions is a part of good practice it is important to identify factors that may enhance or inhibit questioning behaviour. We looked at a number of factors. Working in a small practice was associated with a significantly lower rate compared with practising in a larger one. This is consistent with the findings of Ely's study of rural doctors(4) and possibly supports concerns about doctors practising in isolation.
Answering of questions
The second part of our hypothesis concerned the success with which
doctors are able to answer their questions. In this study the doctors
had obtained an answer to most (61%) of their clinical questions by
the end of the consulting session. A further 18% were answered within
a week of the consultation. In all, 79% were answered by the end of
the study. This is similar to Ely's findings of 88%.(4) By
contrast, Covell found that only 30% of questions were answered at the
time of the consultation, although the doctors expected to find an
answer to more than half of their questions later.(2)
Gorman found that only 30% of questions were pursued at
all.(3) Smith concluded that "most of the questions
generated in consultations go unanswered."(10) The excess
of unanswered questions in other studies may be partly due to the
stimulation of questions by the study, which doctors were consequently
less motivated to seek an answer.(2)
Study limitations
Our study was limited by the small number of doctors who
participated (27), and further research is needed to confirm these
findings. We have not solved the problem of how to identify questions
without either stimulating or missing them.(9) Our reliance
on the doctors to write down questions unaided may have been less
reliable than a face to face approach. The method is also likely to
function as an educational intervention, making repeat testing
problematic. In this study we did not attempt repeat testing, but, were
the method to be used to evaluate an intervention, a good control group
would be essential.
Use of information sources
Australian cities have a relatively high provision of both general
practitioners and specialists compared with Britain. General
practitioners do not have fixed lists of patients and so have a limited
"gatekeeping" role. These factors may partly account for the
frequent use of specialists for information. The sources of information
used to answer questions follow the pattern described in other
studies.(2-4)(7,8)(11-13) "Desk top" references and
human sources were used far more than textbooks, journals, and
electronic sources. This is consistent with the belief that
accessibility is a major factor in determining doctors' choice of
information source.(12-14) It may also reflect doctors'
need for what Forsythe described as "informal
information."(6) This concerns "how to apply the rules
and about exceptions to them" and requires judgment, which human
sources are most likely to offer.
Evidence based medicine advocates formal appraisal of the validity and relevance of evidence.(1) Adopting evidence based medicine therefore implies a change towards sources of information whose validity can be formally assessed. Doctors may be reluctant to make this change if they value the human judgment and accessibility of their current sources more highly than the more transparent validity of alternatives.(13,14)
Factors that might motivate doctors to change the sources of information they use include an excess of unanswered questions and a dissatisfaction with their current sources. We found little evidence of either. Rather, the picture this study presents is of a stable system in which doctors find answers to most of their clinical questions and seem reasonably happy with the sources of information they currently use. Evidence based medicine may therefore make slow progress until doctors become more questioning in their routine practice. The skill of asking the right questions deserves as much attention as the skills of information searching, critical appraisal, and audit have received.
| Key Messages | ||||||||||||
|
We thank the general practitioners of the Perth Central Coastal
Division for their willingness to participate in this study. We also
thank Max Kamien, Jim Dickinson, and Frank Mansfield of the Department
of General Practice, University of Western Australia, and Ian Russell,
Clare Wilkinson, and other members of the North Wales General Practice
Research Club for their help and support.
Funding: Extended study leave payments from the NHS; Glaxo
Medical Fellowship; Travel Grant from Department of Postgraduate
Studies, University of Wales College of Medicine; Lilly
Pharmaceuticals; and RCGP Travel Scholarship.
(Accepted 23 September 1997)
Conflict of interest: None.
Pontilen,
Rhewl,
Ruthin,
Denbighshire LL15 1UL
A Richard
Barrie, continuing medical education tutor for general
practice
Department of General Practice,
University of Western
Australia,
Perth,
Western Australia
Alison M
Ward, research fellow
Correspondence to: Dr Barrie
References
1 Sackett D L, Rosenburg W M C. The need for evidence-based
medicine. J R Soc Med 1995;88:620-4.
2 Covell D G, Uman G C, Manning P R. Information needs in office
practice: are they being met? Ann Intern Med
1985;103:596-9.
3 Gorman P N, Helfand M. Information seeking in primary care: how
physicians choose which clinical questions to pursue and which to leave
unanswered. Med Decis Making 1995;15(2):113-9.
4 Ely J W, Burch R J, Vinson D C. The information needs of family
physicians: case-specific clinical questions. J Fam
Pract 1992;35:265-9.
5 Timpka T, Arborelius E. The GPs dilemmas: a study of knowledge
need and use during healthcare consultations. Methods Inf
Med 1990;29(1):23-9.
6 Forsythe D E, Buchanan B G, Osheroff J A, Miller R A. Expanding
the concept of medical information: an observational study of
physicians' information needs. Comput Biomed Res
1992;25:181-200.
7 Dee C. Information needs of the rural physician; a descriptive
study. Bull Med Libr Assoc 1993;81:259-64.
8 Timpka T, Ekstrom M, Bjurulf P. Information needs and
information seeking behaviour in primary health care. Scand J
Prim Health Care 1989;7:105-9.
9 Gorman P N. Information needs of physicians. J Am Soc
Inf Sci 1995;46:729-36.
10 Smith R. What clinical information do doctors need?
BMJ 1996;313:1062-8.
11 Gruppen L D, Wolf F M, Van Voorhees C, Stross J K. Information
seeking strategies and differences among primary care physicians.
Mobius 1987;7(3):18-26.
12 Gruppen L D. Physician information seeking: improving relevance
through research. Bull Med Libr Assoc 1990;78:165-71.
13 Connelly D P, Rich E C, Curley S P, Kelly J T. Knowledge resource
preferences of family physicians. J Fam Pract
1990;30:353-9.
14 Curley S P, Connelly D P, Rich E C. Physicians use of medical
knowledge resources: preliminary theoretical framework and findings.
Med Decis Making 1990;10(4):231-41.
Home | Current contents | Past issues | Classified ads | Career Focus | Feedback
Collections | About this site | About the BMJ | BMA | Medline