John M. Wilkinson

Barriers and Decisions When Answering Clinical Questions at the Point of Care: A Grounded Theory Study

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.

Value and Process of Curbside Consultations in Clinical Practice: A Grounded Theory Study

OBJECTIVES To clarify the value and process of the curbside consultation and identify ways to optimize this activity. PARTICIPANTS AND METHODS We conducted 13 focus groups at an academic medical center and outlying community sites (September 2011 to January 2013), involving a purposive sample of 54 primary care and subspecialist internal medicine and family medicine physicians. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify benefits, liabilities, mechanisms, and potential improvements related to curbside consultations. RESULTS We developed a model describing the role and process of the curbside consultation. Focus group participants perceived that curbside consultations add particular value in offering immediate, individualized answers with bidirectional information exchange, and this in turn expedites patient care and elevates patient confidence. Despite the uncompensated interruption and potential risks, experts provide curbside consultations because they appreciate the honor of being asked and the opportunity to help colleagues, expedite patient care, and teach. Key decisions for the initiator (each reflecting a potential barrier) include whom to contact, how to contact that expert, and how to determine availability. Experts decide to accept a request on the basis of personal expertise, physical location, and capacity to commit time and attention. Participants suggested systems-level improvements to facilitate expert selection, clarify expert availability, enhance access to clinical information, and acknowledge the experts effort. CONCLUSIONS Curbside consultations play an important role in enhancing communication and care coordination in clinical medicine, but the process can be further improved. Information technology solutions may play a key role.

Impact of collaborative care for depression on clinical, functional, and work outcomes: A practice-based evaluation

Background:The impact of collaborative care (CC) on depression and work productivity in routine, nonresearch primary care settings remains unclear due to limited evidence. Methods:This prospective study examined depression and work outcomes (eg, absenteeism, presenteeism) for 165 individuals in CC for depression versus 211 patients in practice as usual in a multisite primary care practice. Results:CC predicted greater adjusted 6-month improvements in treatment response, remission, and absenteeism versus practice as usual. Response/remission increased productivity overall. Conclusions:CC increased clinical and work improvements in a nonresearch care setting. Insurers and employers should consider CCs work benefits in developing payment structures.

Patient self-assessment factors predictive of persistent depressive symptoms 6 months after enrollment in collaborative care management.

Collaborative care management (CCM) is effective for improving depression outcomes. However, a subset of patients will still have symptoms after 6 months. This study sought to determine whether routinely obtained baseline clinical, demographic, and self‐assessment variables would predict which patients endorse persistent depressive symptoms (PDS) after 6 months. By estimating the relative risk associated with the patient variables, we aimed to outline the combinations of factors predictive of PDS after CCM enrollment.

Health Promotion in a Changing World: Preparing for the Genomics Revolution

All health professionals must become actively engaged in preparing for the genomics revolution. Healthy lifestyles will continue to be of utmost importance, and we must maintain a balance between health promotion activities and genomic-based tests and therapies. We must understand the specific changes likely to occur as advances in genomics are developed and applied to medicine, as well as their ethical, social, and legal implications. We must develop new, Web-based systems and new educational models to most appropriately incorporate these changes into routine practice. Finally, we must offer timely, useful advice and guidance to the public as well as to policymakers in order to maintain realistic expectations and to ensure adequate and balanced funding for health promotion initiatives and research.

Depression Screening, Diagnosis, and Treatment Across the Lifespan

This article focuses on six basic components of more effective depression care, emphasizing systems of team-based and collaborative care for diagnosis, monitoring, and follow-up. It also emphasizes the principles of stepped care and proactive and timely intensification of treatment, and discusses various augmentation strategies that all primary care providers could more readily employ.