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1.  What questions about patient care do physicians have during and after patient contact in the ED? The taxonomy of gaps in physician knowledge 
Emergency Medicine Journal : EMJ  2007;24(10):703-706.
Objectives
To categorise questions that emergency department physicians have during patient encounters.
Methods
An observational study of 26 physicians at two institutions. All physicians were followed for at least two shifts. All questions that arose during patient care were recorded verbatim. These questions were then categorised using a taxonomy of clinical questions.
Results
Physicians had 271 questions in the course of the study. The most common questions were about drug dosing (35), what drug to use in a particular case (28), “what are the manifestations of disease X” (23), and what laboratory test to do in a situation (21). Notably lacking were questions about medication costs, administrative questions, questions about services in the community, and pathophysiology questions.
Conclusions
Emergency department physicians tend to have questions that cluster around practical issues such as diagnosis and treatment. In routine practice they have fewer epidemiologic, pathophysiologic, administrative, and community services questions.
doi:10.1136/emj.2007.050674
PMCID: PMC2658437  PMID: 17901270
2.  Patient-Care Questions that Physicians Are Unable to Answer 
Objective
To describe the characteristics of unanswered clinical questions and propose interventions that could improve the chance of finding answers.
Design
In a previous study, investigators observed primary care physicians in their offices and recorded questions that arose during patient care. Questions that were pursued by the physician, but remained unanswered, were grouped into generic types. In the present study, investigators attempted to answer these questions and developed recommendations aimed at improving the success rate of finding answers.
Measurements
Frequency of unanswered question types and recommendations to increase the chance of finding answers.
Results
In an earlier study, 48 physicians asked 1062 questions during 192 half-day office observations. Physicians could not find answers to 237 (41%) of the 585 questions they pursued. The present study grouped the unanswered questions into 19 generic types. Three types accounted for 128 (54%) of the unanswered questions: (1) “Undiagnosed finding” questions asked about the management of abnormal clinical findings, such as symptoms, signs, and test results (What is the approach to finding X?); (2) “Conditional” questions contained qualifying conditions that were appended to otherwise simple questions (What is the management of X, given Y? where “given Y” is the qualifying condition that makes the question difficult.); and (3) “Compound” questions asked about the association between two highly specific elements (Can X cause Y?). The study identified strategies to improve clinical information retrieval, listed below.
Conclusion
To improve the chance of finding answers, physicians should change their search strategies by rephrasing their questions and searching more clinically oriented resources. Authors of clinical information resources should anticipate questions that may arise in practice, and clinical information systems should provide clearer and more explicit answers.
doi:10.1197/jamia.M2398
PMCID: PMC2244897  PMID: 17460122
3.  Answering Physicians' Clinical Questions: Obstacles and Potential Solutions 
Objective: To identify the most frequent obstacles preventing physicians from answering their patient-care questions and the most requested improvements to clinical information resources.
Design: Qualitative analysis of questions asked by 48 randomly selected generalist physicians during ambulatory care.
Measurements: Frequency of reported obstacles to answering patient-care questions and recommendations from physicians for improving clinical information resources.
Results: The physicians asked 1,062 questions but pursued answers to only 585 (55%). The most commonly reported obstacle to the pursuit of an answer was the physician's doubt that an answer existed (52 questions, 11%). Among pursued questions, the most common obstacle was the failure of the selected resource to provide an answer (153 questions, 26%). During audiotaped interviews, physicians made 80 recommendations for improving clinical information resources. For example, they requested comprehensive resources that answer questions likely to occur in practice with emphasis on treatment and bottom-line advice. They asked for help in locating information quickly by using lists, tables, bolded subheadings, and algorithms and by avoiding lengthy, uninterrupted prose.
Conclusion: Physicians do not seek answers to many of their questions, often suspecting a lack of usable information. When they do seek answers, they often cannot find the information they need. Clinical resource developers could use the recommendations made by practicing physicians to provide resources that are more useful for answering clinical questions.
doi:10.1197/jamia.M1608
PMCID: PMC551553  PMID: 15561792
4.  Obstacles to answering doctors' questions about patient care with evidence: qualitative study 
BMJ : British Medical Journal  2002;324(7339):710.
Objective
To describe the obstacles encountered when attempting to answer doctors' questions with evidence.
Design
Qualitative study.
Setting
General practices in Iowa.
Participants
9 academic generalist doctors, 14 family doctors, and 2 medical librarians.
Main outcome measure
A taxonomy of obstacles encountered while searching for evidence based answers to doctors' questions.
Results
59 obstacles were encountered and organised according to the five steps in asking and answering questions: recognise a gap in knowledge, formulate a question, search for relevant information, formulate an answer, and use the answer to direct patient care. Six obstacles were considered particularly salient by the investigators and practising doctors: the excessive time required to find information; difficulty modifying the original question, which was often vague and open to interpretation; difficulty selecting an optimal strategy to search for information; failure of a seemingly appropriate resource to cover the topic; uncertainty about how to know when all the relevant evidence has been found so that the search can stop; and inadequate synthesis of multiple bits of evidence into a clinically useful statement.
Conclusions
Many obstacles are encountered when asking and answering questions about how to care for patients. Addressing these obstacles could lead to better patient care by improving clinically oriented information resources.
What is already known on this topicDoctors are encouraged to search for evidence based answers to their questions about patient care but most go unansweredStudies have not defined the obstacles to answering questions in a systematic mannerA comprehensive description of such obstacles has not been presentedWhat this study addsFifty nine obstacles were found while attempting to answer clinical questions with evidence; six were particularly salientThe obstacles were comprehensively described and organised
PMCID: PMC99056  PMID: 11909789
5.  A taxonomy of generic clinical questions: classification study 
BMJ : British Medical Journal  2000;321(7258):429-432.
Objective
To develop a taxonomy of doctors' questions about patient care that could be used to help answer such questions.
Design
Use of 295 questions asked by Oregon primary care doctors to modify previously developed taxonomy of 1101 clinical questions asked by Iowa family doctors.
Setting
Primary care practices in Iowa and Oregon.
Participants
Random samples of 103 Iowa family doctors and 49 Oregon primary care doctors.
Main outcome measures
Consensus among seven investigators on a meaningful taxonomy of generic questions; interrater reliability among 11 individuals who used the taxonomy to classify a random sample of 100 questions: 50 from Iowa and 50 from Oregon.
Results
The revised taxonomy, which comprised 64 generic question types, was used to classify 1396 clinical questions. The three commonest generic types were “What is the drug of choice for condition x?” (150 questions, 11%); “What is the cause of symptom x?” (115 questions, 8%); and “What test is indicated in situation x?” (112 questions, 8%). The mean interrater reliability among 11 coders was moderate (κ=0.53, agreement 55%).
Conclusions
Clinical questions in primary care can be categorised into a limited number of generic types. A moderate degree of interrater reliability was achieved with the taxonomy developed in this study. The taxonomy may enhance our understanding of doctors' information needs and improve our ability to meet those needs.
PMCID: PMC27459  PMID: 10938054
6.  Analysis of questions asked by family physicians regarding patient care 
Western Journal of Medicine  2000;172(5):315-319.
Objectives To characterize the information needs of family physicians by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. Design An observational study in which investigators visited physicians for two half-days and collected their questions. Taxonomies were developed to characterize the clinical topic and generic type of information sought for each question. Setting Eastern Iowa. Participants Random sample of 103 family physicians. Main outcome measures Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; and information resources used. Results Participants asked a total of 1,101 questions. Questions about drug prescribing, obstetrics and gynecology, and adult infectious disease were most common, comprising 36% of the total. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?” Answers to most questions (n = 702 [64%]) were not immediately pursued, but of those pursued, most (n = 318 [80%]) were answered. Physicians spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search. Conclusions Family physicians in this study did not pursue answers to most of their questions. Questions about patient care can be organized into a limited number of generic types, which could help guide the efforts of knowledge-base developers.
PMCID: PMC1070879  PMID: 18751285
7.  Analysis of questions asked by family doctors regarding patient care 
BMJ : British Medical Journal  1999;319(7206):358-361.
Objectives
To characterise the information needs of family doctors by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases.
Design
Observational study in which investigators visited doctors for two half days and collected their questions. Taxonomies were developed to characterise the clinical topic and generic type of information sought for each question.
Setting
Eastern Iowa.
Participants
Random sample of 103 family doctors.
Main outcome measures
Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; information resources used.
Results
Participants asked a total of 1101 questions. Questions about drug prescribing, obstetrics and gynaecology, and adult infectious disease were most common and comprised 36% of all questions. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?” Answers to most questions (702, 64%) were not immediately pursued, but, of those pursued, most (318, 80%) were answered. Doctors spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search.
Conclusions
Family doctors in this study did not pursue answers to most of their questions. Questions about patient care can be organised into a limited number of generic types, which could help guide the efforts of knowledge base developers.
Key messagesQuestions that doctors have about the care of their patients could help guide the content of medical information sources and medical trainingIn this study of US family doctors, participants frequently had questions about patient care but did not pursue answers to most questions (64%)On average, participants spent less than 2 minutes seeking an answer to a questionThe most common resources used to answer questions included textbooks and colleagues; formal literature searches were rarely performedThe most common generic questions were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?”
PMCID: PMC28191  PMID: 10435959

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