Scandinavian Journal of Primary Health Care

ISSN: 0281-3432 (Print) 1502-7724 (Online) Journal homepage: http://www.tandfonline.com/loi/ipri20

The Influence of General Practitioners' Knowledge about their Patients on the Clinical DecisionMaking Process Per Hjortdahl To cite this article: Per Hjortdahl (1992) The Influence of General Practitioners' Knowledge about their Patients on the Clinical Decision-Making Process, Scandinavian Journal of Primary Health Care, 10:4, 290-294, DOI: 10.3109/02813439209014076 To link to this article: http://dx.doi.org/10.3109/02813439209014076

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Date: 15 March 2016, At: 12:29

Scand J Prim Health Care 1992; 10: 290-294

The Influence of General Practitioners’ Knowledge about their Patients on the Clinical Decision-Making Process PER HJORTDAHL Department of General Practice, University of Oslo, Norway

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Hjortdahl P. The influence of general practitioners’ knowledge about their patients on the clinical decision-making process. Scand J Prim Health Care 1992; 10: 290-4. Continuity of care is claimed to be an important and integral part of general practice. A main result of continuity is the doctor’s accumulated knowledge about his or her patients. The objective of the present study was to evaluate the modifying effects of this knowledge on the decision-making process that takes place in consultations, as experienced by practitioners. A representative sample of 133 Norwegian general practitioners evaluated a total of 3918 of their own consultations. The main independent variable was the doctor’s own subjectively evaluated knowledge about the patient’s medical history, while the major outcome measures included the perceived influence of accumulated knowledge on the consultation process in general, and on the diagnostic and management decisions in particular. In two-thirds of all consultations, or in three out of four in which the doctor had previous knowledge about the patient, this knowledge was considered to,be clinically useful. In more than one-third of all consultations with previously unknown patients, this lack of information was felt to be a hindrance. Among patients with new medical problems and when the doctor had prior knowledge about the patient, this knowledge was felt to have significantly more therapeutic than diagnostic impact. Accumulated knowledge was generally felt to be of most help in consultations due to psycho-social problems, and was of special diagnostic value in patients presenting new, unspecific problems such as fatigue, fever, and generalized pain. This study indicates that accumulated knowledge about the patient is felt by the general practitioners to play an important and integral part in their clinical decision-making process. Key words: continuity of care, accumulated knowledge, decision-making, diagnostic process, management decisions, consultations, general practice. Per Hjortdahl, MD, Department of General Practice, University of Oslo, Fr. Stangs gate 11/13,N-0264Oslo, Norway.

Decision-making is basic to clinical medicine. In all consultations doctors make judgements on the basis of probability (1,2). General practice is claimed to be unique as a medical speciality by virtue of its own decision-making process and by the context within which this decision-making occurs (3). Several models for the diagnostic process taking place in consultations have been suggested (2). Foremost among these is the hypothetico-deductive strategy (4). According to this model the doctor forms one or several hypotheses based on the presented reasons for encounter, signs or symptoms early in the consultation, and through hypothesis testing a conclusion or diagnosis is reached (4). Related to this conclusion a plan for action, or a management strategy may be formulated. Basic to this process is the doctor’s general knowledge, attitudes, and skills in relation to diseases applied to knowledge and Scand J Prim Health Care 1992; 10

understanding of the individual patient’s illness (5). This process may be modified by factors related to the doctor-patient relationship. Unless faced with a new patient with no previous record, the doctors bring to most consulations a background of knowledge about the patient’s previous and continuing problems and risk factors. Continuity of care is claimed to be an integral part of the doctorpatient relationship in general practice (6). One important result of continuity is the doctor’s accumulated knowledge about the patient (7). This knowledge-base influences the use of specific resources in the consultation, such as laboratory tests and referrals (S), but one could also postulate that it had an influence on the decision-making process in general. The aim of the present paper was to evaluate how often and to what extent the general practitioners’ accumulated knowledge about their

The influence of general practitioners' knowledge

29 1

Table I. Influence of accumulated knowledge about the patient on the decision-making process of the consultation. Results are numbers (percentages). ~

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Previous knowledge

Influence of accumulated knowledge on the decision making process Great hindrance

Some hindrance

Little or no influence

Some help

Great help

None Slight Some Good Excellent

18 (5) 5 (1) 0 0 0

152 (39) 112 (12) 9 (1) 5 (4) 4 (1)

218 (55) 363 (39) 213 (20) 161 (16) 73 (14)

5 (1) 350 (38) 491 (46) 320 (31) 106 (21)

0 90 (10) 350 (33) 538 (53) 333 (65)

393 (100) 920 (100) 1063 (100) 1024 (100) 516 (101)

Total

23 (I)

282 (7)

1028 (26)

1272 (32)

1311 (33)

3916' (99)

Total

'2 cases missing.

patients was felt to modify the consultation process in general, and the diagnostic and management decisions in particular. SUBJECTS A N D METHOD During the spring of 1987 a random sample of 133 Norwegian general practitioners were asked to record 30 consecutive consultations each. Both scheduled and unscheduled consultations with patients of all ages were included, but telephone contacts, house calls, on-call services, and organized preventive work such as well-baby clinics were excluded. Because revisits were excluded, the recording period, which lasted 2-5 days, involved consultations with 30 different patients. Immediately after each consultation the doctor completed a two page questionnaire related to the reason for contact, prior knowledge about the patient, and the impact of this knowledge on the decision-making process. The main reason for consultation was noted by the doctor and subsequently coded by the author in accordance with the new International Classification of Primary Care, ICPC (9). The reason for contact was recorded as new if the patient had not previously consulted the doctor for this specific problem. The doctor indicated his or her knowledge about the patient's medical history, personality, and social situation prior to the consultation on five-point scales, ranging from none to excellent. In a previous paper close correlation was demonstrated between these types of knowledge (7). In the present analysis the doctor's knowledge about the patient's medical history has been taken as a proxy for his or her total knowledge about the patient. The influence of this knowledge on the consultation in general, and 21'

on the diagnostic process and the management strategy in particular, was subjectively evaluated by the practitioner on individual five-point scales. Each scale had the following categories; great hindrance. some hindrance, little o r no impact, some help, and great help. Data tabulations were assessed by chi-square tests. Multiple regression was used to evaluate the influence of age and sex of patient and of doctor on the decision-making process (10). RESULTS All but of the 133 general pracititioners who had agreed to take part in the study recorded their consultations. Of 3 990 possible records, 3 918 (98%) were returned. The participating doctors were representative as to age, geographic distribution, and means of reimbursement of the total general pratitioner population of Norway (11). The patients showed similar age, gender, and morbidity patterns as those found in previous Norwegian general practice surveys (12, 13). Multivariate regression demonstrated no significant relationships between the age and sex of the patient and the doctor, and the impact of accmulated knowledge about the patient on the doctor's clinical judgement. Age and sex are thus not included in the subsequent analyses. The doctor's evaluation of the influence of knowledge about the patient on the consultation is given in Table I. In 2.583 of 3916 (66%) consultations thus evaluated such knowledge was found to be helpful. and it was a great help in one third. I n 305 consultations (8%), previous knawledge or lack there of was seen as a hindrance. Accumulated knowledge was of Scand J Prim Healrh Care 1992: 10

292

P. Hjortdahl

Table 11. Influence of accumulated knowledge about the patient on the diagnostic process in consultations due to new medical problems. Results are numbers (percentages). Previous knowledge

Influence of acccumulated knowledge on the decision making process Great hindrance

None Slight

10 (3) 4 (1) 0 0 0

Some

Good Excellent

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Total

14 (1)

Little or no influence

Some help

(2)

188 (64) 261 (64) 176 (51) 107 (44) 50 (40)

4 77 131 87 45

156 (1 I )

782 (55)

344 (24)

Some hindrance 94 51 6 3 2

(32) (13) (2) (1)

(1)

(19) (38) (36) (36)

Great help.

0 12 (3) 33 (IO) 48 (20) 28 (22)

121 (9)

Total

296 405 346 245 125

( I 00) (100) (101) (101)

(100)

1417 (100)

*2 cases missing.

help in 73% of the 3523 consultations in which the doctor had such prior information, while lack of knowledge was felt to be an obstacle in 44% of the 393 consultations in which the doctor did not have previous knowledge. The influence of accumulated knowledge in diagnostic or management strategies is best evaluated by the doctor’s handling of new medical problems (Tables I1 and 111). Among the 1417 consultations thus evaluated, the doctors had no previous knowledge about 296 patients. This lack of knowledge was considered a diagnostic obstacle in one third of the consultations (Table 11). Among the 1121 consultations due to new problems and when the doctor had prior knowledge, this knowledge was found diagnostically helpful in 41% of the cases. In planning management strategies for patients with new medical problems, the lack of knowledge was felt to be an obstacle in 38% of the cases, while it was of help

in 39% of the consultations with prior knowledge (Table 111). Among 632 consultations due to new medical problems and where prior knowledge was of help, it was of diagnostic help in 461 and of management help in 538 cases. The difference in diagnostic and management help is statistically significant (p > 0.05). Table IV relates the usefulness of prior knowledge to the patients’ reason for consultation. Among patients presenting with psychological problems, previous knowledge was valuable in nine out of ten consultations. Lack of information was especially a hindrance in patients with social problems. Accumulated knowledge played the smallest part in clinical-decision making related to eye, ear and skin problems. Previous knowledge was especially valuable in the diagnostic work-up of new, unspecific problems such

Table 111. Influence of accumulated knowledge about the patient on management strategy in consultations due to new medical problems. Results are numbers (percentages). Previous knowledge

Influence of accumulated knowledge on management strategy

Great

Some

hindrance

hindrance

None Slight

8 (3) 4 (1)

Some

0 0 0

Good

Excelle:nt Total

12 (1)

‘2 cases missing. Scand J Prim Health Care 1992: 10

103 (35) 50 (12) 2 (1) 4(1) 1 (1)

160 ( I I )

Little or no influence

Some help

178 (60) 240 (59) 141 (41) 92 (38) 49 (39)

7 97 167 96 44

(2) (24) (48) (39) (35)

14 (4) 34 (10) 55 (22) 31 (25)

700 (49)

411 (29)

134 ( I O )

Great help

0

Total

296 405 346 245 125

(100)

(100) (101)

(101) (100)

1417 (100)

The influence of general practitioners’ knowledge

293

Table IV. Influence of accumulated knowledge about the patient on the decision-making process, related to rhe patient’s reason for consultation. Great and some hindrance are taken together, as are some and great help. Results are numbers (percentages). ICPC chapter

Influence of accumulated knowledge on the decision-making process Of hindrance Little or no

Of help

Total

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influence General (unspecific problems such as fatigue, fever) Blood, blood-forming organs Digestive Eye Ear Circulatory Musculoskeletal Neurological Psychological Respiratory Skin Endocrine, metabolic and nutritional Urology Pregnancy, childbearing, family planning Female genital system Male genital system Social problems Total

16 (12) 4 (7) 31 (14) 4 (5) 2 i2j 29 (5)

303 (7)

35 (26) 8 (14) 33 (15) 49 (57)

55 (55) 78 (13) 205 (26) 15 (11) 2 (1) 140 (39) 120 (51) 6 (4) 15 (19) 161 (46) 90 (31) 15 (27) 1 (5)

82 (62) 44 (79) 157 (71) 33 (38) 43 (43) 489 (82) 502 (63) 103 (77) 244 (92) 197 (55) 101 (43) 128 (90) 65 (80) 176 (50) 169 (59) 36 (64) 14 (78)

133 (100) 56 (100) 221 (100) 86 (100) 100 (100) 596 (100) 791 (100) 134 (100) 265 (100) 359 (100) 235 (100) 142 (100) 81 (100) 352 (100) 289 (100) 56 (100) 18 (100)

1028 (27)

2583 (66)

3914* (100)

*4 cases missing

as fatigue, fever, and generalized pain, where it was of help in 26 of 31 consultation. Lack of prior knowledge was expressed as a diagnostic problem in 11 of 12 patients presenting with new psychological problems, and in 4 of 6 patients with new social problems. Previous knowledge was of least diagnostic help regarding new skin, eye, or ear related problems. Knowledge about the patient was especially valuable when planning management strategies for patients with new endocrine, metabolic or nutritional problems, when it was found useful in 28 of 30 cases. Insufficient previous knowledge was a hindrance for management plans in 8 of 10 new neurological problems, and it was considered of least management value in consultations related to eye or skin disorders.

DISCUSSION Continuity of care is a desired attribute among Norwegian general practitioners (14). As part of this an overestimation of self-assessed knowledge about

their patients may be present in this study. When interpreting the results, furthermore, it should be remembered that the study focuses on the doctors’ own opinion of how they acted, which is not necessarily the same as what actually took place in the consultation. In two-thirds of all general practitioners’ consultations, or in three out of four consultations when the doctor had prior knowledge about the patient, this knowledge was felt by the doctors to play a part in the decision-making process. Accumulated knowledge about the patient may be used subconsciously as part of the doctor’s tacit knowledge (15), also influencing the context and interpretation of the communication that takes place in the consultation (16). It may furthermore play a more conscious part in the decision-making process. There are basically two ways in which such knowledge may improve judgement in the hypotheticodeductive model in a positive way; by increasing the probability of reacing a correct conclusion, and by reaching the right conclusion more rapidly, thus saving time (2). It is likely that it was this influence of the accumulated knowledge that the general practitioners found as a modiScand J Prim Health Care 1992; I0

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294

P. Hjortdahl

fying, or adjuvant factor in as many as two-thirds of their consultations. Among patients whit new medical problems and when the doctor had previous knowledge, this knowledge was felt to give significantly more therapeutic than diagnostic help. This may partly be due to the diagnostic process being primarily a medical task, based on data gathered in the consultation through history taking and physical examination, while treatment considerations may be more pragmatic, involving the use of accumulated knowledge in deciding which treatment is correct for the patient. In addition, as shown by Howie, general practitioners often go directly from clinical observation and interpretation to treatment strategy, bypassing an intermediate diagnostic process (17). The diagnostic label is often applied post hoc, after the management decisions have taken place. In almost all cases when knowledge played a part, it was felt to be of help, or lack of knowledge a hindrance, which may be viewed as complementary. In nine cases, however, the presence of good or excellent historical knowledge was felt to be an obstacle. The reason for consultation for these patients was psychosocial problems or general complaints. In these cases the doctor may have felt that he or she, on the basis of previous knowledge, too quickly converged o n a conclusion, ending up with a wrong diagnosis or treatment decision. One potential shortcoming of familiarity is that, once established, it is difficult to alter, with the consequent danger of stereotyping the patient (16). Such stereotyping, or prejudice, is probably often unconscious and thus more frequent in general practice than demonstrated in the present study. Accumulated knowledge was generally of most use in clinical judgements involving patients with psychosocial or unspecific problems such as fatigue, fever, and generalized pain. It was thought to be of least diagnostic and managerial importance in new ear, eye, and skin problems. These problems were often minor infections and injuries. Even when previous knowledge was present, as much as 80% of these decisions were felt to be taken on the basis of t h e current clinical presentation alone. This indicates that continuity of care together with doctors’ accumulated knowledge about the patient have different levels of importance for different patient groups, and that they may be of particular importance when managing patients with chronic o r psychosocial problems. Scand J Prim Health Care 1992: I0

This study lends evidence to the claim that general practitioners feel that accumulated knowledge about their patients plays an important and integral part in much of their clinical decision-making process. As patients become increasingly older and have more complex, chronic problems, continuity of care and the accumulation of a knowledge-base about the patient thus appear to become even more important in the future of general practice.

REFERENCES 1. Wulff HR. Rational diagnosis and treatment. An introduction to clinical decision-making. Oxford: Blackwell, 1981. 2. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology. A basic science for clinical medicine. Boston: Little, Brown, 1991. 3. Herbert CP. Figure and ground: Reframing the study of decision making in family practice. Fam Med 1988; 20: 31S20. 4. Elstein AS, Shulman LS, Spraflca SA. Medical problem-solving. An analysis of clinical reasoning. Cambridge: Harvard University Press, 1978. 5. Bentsen BG. The diagnostic process in primary care. In: Fry J (ed.). Primary Care. London: Heineman Medical Books, 1980. 6. McWhinney IR. A textbook of family medicine. New York: Oxford University Press, 1989. 7. Hjortdahl P. Continuity of care: general practitioners’ knowledge about, and sense of responsibility toward their patients. Fam Pract 1992; 9: 3-8. 8. Hjortdahl P, Borchgrevink CF. Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. BMJ 1991; 303: 1181-4. 9. Lamberts H, Wood M, eds. ICPC. International classification of primary care. Oxford: Oxford University Press, 1987. 10. Hosmer DW, Lemeshow S. Applied logistic regression. New York: Wileys, 1989. 11. Hjortdahl P. General practice and continuity of care: organizational aspects. Fam Pract 1989; 6: 292-8. 12. Rutle 0. Pasienten fram i lyset - Analyse av legekontaktar i primerhelsetenesta (Getting the patient into the limelight. An analysis of contacts in primary health care). Rapport nr 111983. Oslo: SIFFs gruppe for helsetjensteforskning, 1983. 13. Nylenna M. Why do our patients see us? Scand J Prim Health Care 1985; 3: 15.5-62. 14. Hjortdahl P. Ideology and reality of continuity of care. Fam Med 1990; 22: 361-4. 15. S c h h DA. The reflective practitioner. How professionals think in action. New York: Basic Books, 1983. 16. Helman CG. The role of context in primary care. J R Coll Gen Pract 1984; 34: 547-50. 17. Howie JGR. Diagnosis - the Achilles heel? J R Coll Gen Pract 1972; 22: 241-58.

The influence of general practitioners' knowledge about their patients on the clinical decision-making process.

Continuity of care is claimed to be an important and integral part of general practice. A main result of continuity is the doctor's accumulated knowle...
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