The dawn of the information age has brought an epochal shift in the pace of novel medical evidence. Remaining up to date with this increasing volume of information has been described akin to ‘drinking from a firehose’, as put by one author,1 who further laments, ‘… while the diameter has gotten wider, the water pressure has not been reduced’.1 To remain current and relevant, a contemporary physician requires skills in effective and efficient information seeking.
In general practice, clinicians are time poor, and patient complexity is increasing.2–4 These factors, along with care delivery occurring in a single space (the consultation room), demand that doctors seek the information they need in view of the patient. This practice has been demonstrated to improve the accuracy of answers to clinical questions, clinician confidence in decision making and, in turn, patient outcomes.5–7
The impacts of point-of-care information seeking
Despite the benefits, concerns remain over the impacts of information seeking at the point of care. Clinicians fear losing face or being seen as incompetent, and are often impeded by feeling rushed, awkward or time constrained.8,9 This concern is likely overstated, as previous studies have shown a mismatch in the degree to which doctors think patient confidence will be decreased and that which is reported by patients.8 Patients appear to be generally understanding of a doctor’s need to search, but younger patients may be less tolerant of the practice.8
Tips for point-of-care information seeking
Here we present practical suggestions for how doctors in ambulatory settings could incorporate the findings of our recently published qualitative study of semistructured interviews with Australian general practice patients exploring their perspectives on doctors’ information seeking at the point of care.10
Given that our study is the only piece of research exploring the patient voice on this topic, we have also drawn from literature in adjacent areas (eg the use of electronic medical records, computers and other digital devices in the consulting room). Box 1 provides a summary of the seven tips outlined below.
| Box 1. Practical tips for point-of-care information seeking |
1. Set up the consultation space
- Set up the consultation room to allow screen sharing
2. Understand the footing of the consultation
- Build rapport with new patients
- Be mindful of a patient’s emotional state
- Culturally discordant consultations may require particular attention as trust may be less inate
- Trusting patients may be more tolerant of an information-seeking faux pas
3. Communication skills
- Active listening
- Focused attention
- Appropriate phrasing
- Patient-centred discussion
- Open body language
4. Bring the patient on the journey of searching
- Ask then tell
- Share your screen
- Educate the patient: where to search and reliable sources
- Consider thinking out aloud
- Never lose sight that the question is related to the patient; involve the patient in what you find and how it relates to them
5. Search well
- Use appropriate point-of-care sources: avoid ‘Google’
- Provide superior interpretation and application of information
- Take your time, but not too long; defer if needed
6. Be transparent
- You cannot be all-knowing, but you can be honest and comfortable in your ability
7. Build the blocks for the next consultation
- Build rapport
- Educate the patient on future information-seeking needs
- Seek patient feedback
|
Tip 1: Set up the consultation space to facilitate information seeking
The inclusion of a computer in the consultation room brings a third party into the space, forcing patients to negotiate the triadic relationship of the doctor, the computer and themselves.11 Patients are generally interested in knowing what a doctor is doing on the computer and appreciate screen sharing.10,12,13 Sharing the computer screen has been reported to increase collaborative decision making and trust.14 When it comes to information seeking, optimising the physical layout of the consultation room to facilitate patient interaction with the computer can allow patients to engage with the process and have greater ownership over the information found.14
Tip 2: Understand the footing of the consultation
No two patients will have the same thoughts about a doctor seeking information during a consultation. However, there are some factors that help gauge a patient’s acceptance of the practice. Strong rapport appears to be one of the most important factors that will increase patient tolerance. Clinicians therefore need to be particularly careful around patients they do not know. Information seeking is, to some degree, always seen as a withdrawal from the emotional bank account of the therapeutic relationship; therefore, deposits are needed before seeking information.9,10
Another group of patients to be mindful of are those experiencing certain emotional states (ie anxiety, vulnerability), because they may be less tolerant to attention diverted to information seeking.10 Culturally discordant consultations also need particular attention because trust and understanding may be less innate and need to be built for the patient to accept a point-of-care search.10 Information seeking with these patient groups may need to be delayed until late in the consultation, once rapport has been established, the agenda acknowledged and space made for vulnerable emotions to sit. In some cases, information seeking at the point of care is never appropriate, and clinicians’ information needs may need to be met after the consultation or in another space.9,10
On the other side of the equation are patients who have high trust in mainstream medicine; these individuals are unlikely to be phased, providing attention is paid to the consultation skills (see Tip 3).10
Tip 3: Communication skills: ‘Earning the right to search’
It has long been understood that communication skills are as important as clinical knowledge and procedural skills in delivering effective healthcare.15 This principle applies equally to the consultation in which a clinician accesses information. Our study identified five key skills for improving patient satisfaction and improving trust: active listening, focused attention, appropriate phrasing, patient-centred discussion and open body language.10 Not surprisingly, these are the same factors that have received much focus in the literature.15,16
Patients want to be listened to and have their concerns heard.10 A doctor using a computer in the consultation room without adequate care can lead to clinician distraction, amplification of poor communication styles and loss of rapport.13 Patients request that prior to accessing information a doctor must first ‘earn the right’ to turn to a resource. This ‘right’ is earned through assessing the patient thoroughly and focusing attention actively before seeking information. Patients expect their doctor to take a history and perform an examination before going to search for information; this is demonstrated in the case study in Box 2.10,17 The next step is to phrase the need to search correctly. Patients would prefer that doctors refresh old knowledge rather than learn something completely new; thus, terms such as ‘double-checking’ or ‘confirming’ are considered most appropriate.10
| Box 2. Case study 1 |
Earning the right to search
Dr B greets a patient, Ms R, whom he has seen a few times. Ms R suffers from generalised anxiety and has expressed worry over health issues at previous consultations. Today she presents with hair loss over the previous two months, which she has noticed clogging the drain of her shower. Ms R has read online that lupus can cause hair loss and would like to consider treatment for this. Dr B recognises that this is an information gap and he will need to look up the causes and treatments of alopecia. While practically useful to find this information immediately, Dr B continues to focus on Ms R and takes a thorough history about the hair loss and conducts a focused examination. Dr B confidently declares that although he feels that lupus is possible, he would need to double-check the causes of alopecia to be confident in the diagnosis. Turning to a trusted online dermatology website, Dr B and Ms R learn about the causes of alopecia and agree that the presentation is more likely in keeping with telogen effluvium. Together, they discuss the causes and treatment options.
This case demonstrates the benefit of delaying information seeking until after taking an assessment of the patient, building both rapport and the level of trust the patient has. |
The clinician also needs to be mindful of how information seeking may affect body language.16 Eye contact can be lost, and the body posture can become closed; these issues can be managed both through clinician awareness and by clearly verbalising the need to search.10
Ultimately, for patients, clinicians seeking information during a consultation is more about interacting with them than the skill of searching.
Tip 4: Bring the patient on the journey
Never lose sight that the question is related to the patient, not just a gap in the clinician’s knowledge. Before searching, the clinician should first ask the patient for their ideas and understanding.10 This allows the patient to have input into the search and includes them in the experience of learning together.
Increasingly, patients will have conducted their own online search prior to the consultation, and this should be elicited prior to conducting another search at the point of care. Encouraging patients to disclose a prior search validates them as active and engaged partners in their care and allows the clinician to check the factual accuracy of the information.18 Openness to discussion of online information can also reduce patient perceptions of physician reticence or fear of embarrassment.18
Sharing the screen and thinking out loud are ideal ways to bring the patient on the journey, as demonstrated in the case study in Box 3.10 Patients particularly appreciate this practice, because the information that is being sought is directly related to their personal healthcare.
| Box 3. Case study 2 |
Bringing the patient on the journey
Dr M consults with a patient new to her, Mr T, who has severe osteoporosis. Today Mr T has brought in a piece of paper on which he has written ‘Evenity’ (romosozumab), the name of a new drug Mr T had seen on the news for osteoporosis. He is asking about the side effects and benefits over his denosumab therapy. After taking time to hear Mr T’s concerns and expectations, Dr M suggests ‘Why don’t we look this up together’ and turns to a reputable online medicines database to search for further information regarding romosozumab. Reading the information found together, Dr M concedes that there is more complex information here. Dr M suggests that ‘While the results look promising, I will need more time to look into this and get back to you’, citing that there are restrictions on this new drug, and ‘We need to understand not only how well this drug works, but also how this might fit into your care’. Mr T agrees and will revisit this at their next appointment in a month. Although Mr T has asked a question outside of Dr M’s current knowledge, romosozumab is a new drug and he trusts that Dr M will take the time to see whether it is suitable for him, including costs and side effects.
This example highlights the benefits of seeking information together and deferring to a future consultation when it is not possible to succinctly review information at the point of care. |
Patients also feel that information seeking at the point of care is an opportune moment for education on how to find reputable sources and recognise poor- quality information.10
Tip 5: Search well
Patients have a general expectation that doctors have superior search skills and information sources than a lay person. Google, in particular, is seen as unsophisticated and something that a patient would be able to use on their own.10 The time taken to conduct the search is also important to patients. There appears to be a period long enough to reassure the patient that the clinician has been thorough in their search, but not so long that the patient loses patience or confidence in the clinician’s knowledge base.10 It is difficult to know what this duration is; however, if you feel the search is taking too long, your patient probably does too. To reduce the time taken to access reliable and verified sources, it is advisable that clinicians compile a list of trusted databases and websites and have these saved in a location that is familiar and easily accessed (bookmarks, folders etc.). Complex information seeking may require asking the patient to return later (see Box 3). Patients understand this process, especially if they appreciate the complexity involved. The final component to searching well is providing individualised advice to the patient based on the information found. Patients are intolerant of a doctor reading out the information sought without providing interpretation and personalisation.10 Patients appreciate it if their doctor can apply the information to their situation and offer context. If this is done well, it can lead to improved shared decision making and improved therapeutic trust.
Tip 6: Be transparent
Patients generally accept that doctors cannot be all-knowing; however, they appreciate transparency. Signposting through honest declaration of uncertainty is most valued when accompanied by confidence in finding an acceptable answer (see Box 3).10,13 It is better to be aware of and comfortable with the gap in knowledge and show confidence in seeking an answer than to feign knowledge, which will erode trust.
Tip 7: Build the blocks for the next consultation
A patient’s tolerance for a doctor seeking information during the consultation is likely to improve over time. This can be achieved through building strong rapport and educating the patient on the information needs of clinicians working in the information age.10
A key issue that doctors face is the lack of feedback from patients on the impacts of point-of-care information seeking. To get this feedback, it needs to be built into the consultation. This can be achieved through observing patient responses and seeking direct verbal reports. This would allow doctors to modulate their information seeking to best meet the needs and wants of their patients.
Conclusion
Modern medicine is constantly updating, and doctors have an increasing need to search for information at the point of care, in front of the patient. Often cited as a barrier, information seeking is seen by patients as a communication skill. Information seeking can be done with a patient in a way that builds trust and rapport, such that it becomes a value-adding part of the consultation for patients.
Key points
- From a patient’s perspective, seeking information at the point of care is more about communication than searching.
- A clinician needs to earn the right to access information by applying the appropriate consultation skills.
- When you do not know something, be transparent, be confident in knowledge- seeking skills and relate the information back to your patient.