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guidelines. The hope was that if Louisville physicians recognized
their peers as authors, that there would be greater adoption. But
those guidelines were large paper documents and not practical
for practicing physicians to use at patient point of care. They were
just too inconvenient. Today smart phone apps and guidelines
imbedded in electronic health records make for the rapid deployment of just-in-time information for the practicing doctor.
•
Attitudes toward evidence-based medicine: many physicians
in these studies discount EBM as being less relevant than their
own experience, and hold the view that their insight is more
relevant than the numbers in published studies.
•
Peer influence: the variation in adoption of EBM into clinical
practice has as much to do with the norm of the group practice or local medical community as it does with the individual
physician.
•
Patient beliefs: how many of us know that antibiotics are not
necessary for patients with simple sinusitis or upper respiratory
infections but still prescribe them because of patient demand.
We just know that the patient will not follow the rest of our
instructions if we don’t compromise our knowledge. This is so
common, but raises multiple side issues.
•
Tolerance of uncertainty: frequently imaging studies or lab
tests are ordered despite the lack of evidence because of physician worry of what might be. This area is also termed defensive
medicine.
Other studies of physician adoption of evidence based medicine
show age – based variance with older physicians placing more reliance
on their experience, and newer physicians more readily adopting
EBM. But when a group practice is comprised of younger and older
physicians there is a greater sharing of experience and new knowledge
that improves clinical outcomes within the entire group. This used
to be the process occurring in the hospital doctors’ lounge, where
there was more group interchange. Nowadays office-based doctors
are more isolated within their own specialties, at least in person – but
may have quick access to specialist advice through email contacts.
The way doctors learn in their post-residency years has been
evolving, but is still based upon the generation cohorts with older
physicians looking toward CME courses that have clinical relevance
to their own practice, and younger physicians making far greater
use of digital opportunities. The movement by the Boards toward
incorporation of quality improvement processes into maintenance
of certification is a response by the Boards toward recognizing that
the feedback processes of clinical relevance are key to physician
learning. Regardless of style, each doctor can make quality improvements in clinical practice by understanding her or his most effective
learning style.
Learning
Domain
Examples
Visual
Slide presentations, readings, written
case reports
Auditory
Lectures, group discussions, orally
presented case studies
Kinesthetic
Simulations, taking notes, case
management at the bedside.
References
1 NHI Instructor development course principle of adult learning
and instructional system design. https://www.nhi.fhwa.dot.gov/
downloads/freebies/172/PR%20Pre-course%20Reading%20Assignment.pdf (last accessed Jan. 23, 2014)
2 Stead EA, Lecocq Lecture: Gene Stead looks at doctoring. Duke
University Medical Center, April 23, 1993, http://easteadjr.org/
Doctoring.pdf (last accessed Jan. 23, 2014)
3 Swennen MH, van der Heijden GJ, Boeije HR, van Rheenen N,
Verheul FJ, van der Graaf Y, Kalkman CJ. Doctors’ perceptions
and use of evidence-based medicine: a systematic review
and thematic synthesis of qualitative studies. Acad Med. 2013
Sep;88(9):1384-96.
4 Toews J, How and where physician learn. Lecture notes www.
smu.org.uy/dpmc/pracmed/ix_dpmc/toews.pdf
5 Vakani F, Jafri W, Ahmad A, Sonawalla A, Sheerani M. Task-Based
Learning versus Problem-Oriented Lecture in Neurology Continuing Medical Education. J Coll Physicians Surg Pak. 2014
Jan;24(1):23-6
6 von Muhlen M, Ohno-Machado L. Reviewing social media use by
clinicians. J Am Med Infor H\