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Introduction
How best to make decisions about the care of individual patients? For thousands of years, ‘best patient care’ was defined through experience of individual clinicians, passed down from one to another in an apprenticeship model.1 To advance medical education, The Flexner Report 2 aimed to add the burgeoning scientific method to medical care by locating medical training exclusively in medical schools. This report had the twin goals of spurring research into pathophysiology of disease while also teaching clinicians how to use careful reasoning to link findings to a diagnosis. However, this inductive reasoning approach is belied by research showing that numerous approaches to patient care that ‘ought to work’ did not pan out in practice to provide the expected benefit.3 From antiarrhythmic treatment increasing the likelihood of sudden death to the recent finding that vitamin D supplementation in women can increase the risk of hip fractures,4 many medical practices have been shown to cause more harm than would be predicted based on an understanding of pathophysiology.3
In response to the growing awareness of this mismatch between what ought to work and what has been shown to work, the evidence-based medicine (EBM) approach to medical care developed.5 Although EBM has evolved since its initial description to include individual clinical expertise and shared decision-making through an understanding of patients’ values and expectations,6 its fundamental contribution to medicine is its prioritisation of sources of evidence, recognising that findings derived from controlled clinical trials are closer representations of ‘the truth’ than a thorough understanding of pathophysiology or single or limited anecdotes derived from patient care experiences.7 In this model, clinicians are asked to think deductively, relying on results from clinical trials (the evidence of EBM) and acknowledging uncertainty in medicine to guide decisions made for individual patients.8–10 The EBM approach thus requires a paradigm shift in medical decision-making, from one that is mechanistic to one that is probabilistic. However, grounded in the need to evaluate research rigour, the application of the EBM approach to all medical information can feel daunting.
With a growing need to develop a method to help physicians better manage large amounts of information based not only on its validity but also on its relevance in a way that requires minimal time and energy, the ‘information mastery’ (IM) approach was developed as an approach to help physicians apply the concepts of EBM to make decisions in everyday practice. This approach states that the usefulness of any information is related to the relevance of the information, its validity and how much work (effort, expense) needed to obtain the information11–13:
Learning the tenets of IM, which require the acknowledgement of uncertainty as a part of medical practice, can provoke cognitive dissonance as current paradigms to medical decision-making are challenged. As we explored in a previous paper,14 when exposed to the concepts of IM, many learners undergo a transformative learning experience, in which an emotional response to new information propels learners to make behavioural changes.15 During transformational learning, a disorienting dilemma challenges one’s current frame of reference. As this frame of reference is challenged, learners who undergo transformation re-evaluate their underlying assumptions, typically about themselves as well as how they view the world, leading to a new framework, which can affect the way they practice medicine.16 We also found that despite this initial cognitive dissonance, some learners emerge from the experience, and rather than feeling daunted and overwhelmed by medical decision-making, instead feel more autonomous, confident and facile in using evidence to make decisions.14
In this paper, we explore the conceptual underpinnings of IM that drive this perspective transformation in both the behavioural and affective realms. We ask: What are the transformative concepts that comprise an IM approach, and how does this approach further the evolution of clinical decision-making to help clinicians reach the ‘truth’, that is, the best care for their patients?
Methods
The conduct of this study has been previously described.14 We used a qualitative approach to understand the lived experiences (cognitive, affective and behavioural) of 12 current and 9 prior attendees of the 2-day ‘Eighteenth Annual Information Mastery Conference’ conducted on 7–8 November 2013 (and now presented online). Specifically, we applied hermeneutic phenomenological methodology17 18 since this approach allows us to develop a rich description of the phenomena (the learning journeys of conference participants before, during and after the conference), capture deeply personal and social experiences, and evaluate this experience through a particular theoretical lens (transformational learning theory).15 16
We engaged in purposeful sampling, targeting attendees of the 2-day conference (prospective group) and previous conference attendees (retrospective group). We aimed to include 8 to 12 participants in each group to provide enough ‘information-rich cases’19 to reach data saturation. We selected prospective participants based on a survey sent out prior to the conference, with the goal to include: (1) those with no to little previous exposure to IM concepts and (2) a mix of physicians, non-physician clinicians and medical educators; primary care providers and specialists; and participants from various institutions and geographic regions. We chose this profile of participants to best capture the natural and raw responses generated when relatively new and potentially provocative information was presented, regardless of participants’ personal and professional backgrounds. Among the retrospective group, we aimed to include those with a demonstrated record of making significant behavioural changes since attending the conference, based on continued correspondence with the conference instructors. The study received institutional review board approval. We obtained informed consents from all participants prior to data collection.
Among the prospective group, RGS collected data using observation of participants’ responses at the conference, three individual 30-min semistructured interviews before, during and after the conference, and a 50-min focus group during the conference. Among the retrospective group, RGS conducted 30-min interviews to understand what components of IM have been integrated into their current practice of medicine and general worldview. We designed questions around a transformative learning theory framework to assess participants’ evolving thought processes, emotional responses and behavioural changes over time. Transformative learning occurs following receipt of new information that induces a ‘disorienting dilemma’. Learners can either reject the information or embrace it, the latter leading to a deep emotional response that results in a transformed worldview with cognitive and behavioural change in learners.16
We analysed data using thematic analysis model with the use of ATLAS.ti software following six-step process that included development of first- and second-order constructs, themes and subthemes.19 Using a hermeneutic circle to guide analysis, we moved back and forth between the parts (the data from observation, interviews and focus groups) and the whole (evolving understanding of the phenomenon—participants’ learning journeys), allowing us to construct meaning about the transformative learning experience in a circular and iterative approach grounded in data. This resulted in the development of two overall themes identified based on their quality rather than frequency.
We achieved methodological rigour through triangulation, using multiple sources (current and prior conference attendees) in multiple settings (targeting participants at the conference and those who had previously attended and were actively applying the information at their current institution), multiple methods (observation, interviews, focus groups) and researchers (those with medical education, medical and IM backgrounds).20
Results
The current and past participants included physicians and other clinicians at various stages of their professional careers (box 1). Most of the participants, via a preconference survey, described themselves as having a low level of understanding and appreciation of the concepts delivered during the course.
Demographics of participants
Current attendees
Specialty
Primary care: 7
Family medicine: 5
Pediatrics: 1
Internal medicine: 1
Specialty care: 3
Dermatology: 1
Nephrology: 1
Critical care (retired): 1
Non-physicians: 2
Physician-assistant: 1
Pharmacist: 1
Years of practice
0–5 years: 3
6–10 years: 2
11–20 years: 3
21–30 years: 1
30+ years: 3
Gender
Female: 9
Male: 3
Workplace setting
Academic: 12
Hospital-based: 8
Community-based: 3
Single-specialty group: 4
Multi-specialty group: 1
Baseline self-reported level of EBM
Level 0 (novice): 2
Level 1 (using some EBM search engines): 6
Level 2a (teaching EBM): 3
Level 2b (writing EBM synopses): 1
Level 3 (writing EBM guidelines/reviews): 0
Previous attendees
Specialty
Family Medicine: 5
Non-physicians: 4
Chiropractor: 1
Physician-assistant:1
Pharmacist: 2
Age
<40 years: 2
40–50 years: 5
50–60 years: 0
60+ years: 2
Gender
Female: 6
Male: 3
Teaching level
Undergraduate: 6
Graduate: 2
Both: 1
Years since attended the information mastery conference
1 year ago: 3
2 years ago: 2
3 years ago: 3
3+ years ago: 1
EBM, evidence-based medicine.
From our analysis, current and previous attendees who seemed to undergo transformative learning identified eight concepts that uniquely constitute an IM approach to medical decision-making, which we grouped into two general themes. The concepts are illustrated by quotations from attendees.
Theme 1: Uncertainty is an aspect of medical decisions, but steps can be taken to proceed confidently
The move from pathophysiological-based decisions to acknowledging and understanding the play of probability in medical practice requires embracing three concepts:
Uncertainty plays an integral role in medical practice: Probabilistic reasoning requires a shift from away from the approach that a thorough understanding of mechanism of disease will provide clinicians with the right decision. Instead, clinicians must acknowledge the limits to the predictive ability of scientific inquiry in medicine. Clinical decision-making thus becomes a careful weighing of available evidence to determine whether, on average, a medical intervention is likely to cause more good than harm.11 Acknowledging this uncertainty necessitates collaboration with patients to make decisions.21
One participant cites her growing awareness of this concept:
So much of what we do… we’re not going to have high-quality evidence and you still have to look at the patient in front of you and all their other co-morbidities, their social value, and all the psycho-social … and then you’ve got to come to making some decisions with incomplete evidence … that’s OK. And use the evidence when you can and use your professional judgment when you have to.
There is a hierarchy of evidence; not all evidence is created equal: At its core, EBM involves using ‘the best available evidence’, namely research study types with the most rigorous design, such as systematic reviews and randomised controlled trials. This approach requires a recognition that much available clinical information is preliminary. Clinicians should thus consider the quality and rigour of a study in assessing its applicability to making decisions in patient care.22
A participant describes,
Now I have a really highly developed understanding of how to decide the quality of the literature … So, now when I have a question about what to do for a patient, I can identify how strong the available information is that I have to help me make that decision.
Decisions can be made more confidently if based on patient-oriented evidence that matters (POEMS): Research findings that focus on surrogate outcomes, such as risk factors, biological markers and laboratory values, do not necessarily translate into outcomes that benefit patients.3 Instead, clinicians should, whenever possible, make decisions based on the results from outcomes studies that evaluate whether a medical intervention will, on average, help patients live longer, live better or both.11
A participant describes,
I think the big thing I should have learned earlier …. You should be wary of using surrogate endpoints rather than does it help the patient live longer or live better. That was a big one which hadn’t struck me before … looking at A1c wasn’t valid, you should look at how does this therapy change the patient’s life is what you should be looking at, and just because it affects hemoglobin A1c, it doesn’t make it good.
Theme 2: Confidence making medical decisions requires careful curation of one’s knowledge
The move from acquiring information to managing it (organising and applying it) is illustrated by these five concepts:
Medical information can be tainted and biased: Many sources of medical information, such as review articles, clinical practice guidelines and medical education conferences, are based on the interpretation of others and hence potentially coloured by intellectual, professional and financial conflicts of interest. Clinicians must develop the skills to evaluate these information sources rather than to uncritically accept them.1 23–25
A participant reacts to grasping this concept:
We go by expert opinion, expert guidelines, and now we know that all of these things could be biased, because when the guidelines come from a certain group of people, how could things not be biased? So now you know why there are three different guidelines from three different societies about the same thing. I never used to pay attention to their affiliation or the grants from the pharmaceutical companies because I kind of believed them—they’re experts. So, that means that expert opinion may not be all that expert … or the right opinion for me and my patients. It changes everything. I think that’s the most important thing … to question everything that comes to you as evidence.
Learning how to find information may be more important than learning the information itself: Given the rapid production of new information in medicine, clinicians must develop skills and habits for continually updating their knowledge as well as quickly finding answers to clinical questions at the time they need them. Embracing this concept requires discarding the traditional role of clinicians as repositories of unique knowledge and information.26
A participant describes grasping this concept:
This is what I can tell my residents and students—what I was doing probably all the time was not the correct approach; just giving them lectures and presentations is probably not what they need. So once I go back, I think my approach is going to change. I’m going to teach them to look up these sites and decide for themselves … which is good … don’t just go by if I say, ‘this medicine is good for this patient because I say so.’
Curating medical knowledge allows for feeling good about not knowing everything: This role reframing requires acknowledgement that much of the available medical information is not valid (it is preliminary and lacking scientific rigour) or relevant (it does not focus on outcomes that matter to patients).12 Clinicians can safely ignore, without guilt, large portions of the medical literature that need not be considered in care decisions.11 Instead, clinicians have to carefully filter out new information they encounter to avoid being misled.27
A participant explains this concept:
There’s just so much that comes out related to [my specialty]. I can’t read it all. So, to have a way to just rapidly go through this garbage. It’s not worth my time. I can just screen through the entire New England Journal of Medicine every week and it’s like not relevant, not relevant. I [can] very quickly decide what I want to keep. I think I’m getting through a lot more stuff.
Trusted, high-quality information-gathering services should be used instead of attempting to read original research literature: The skills needed for the classic EBM approach of acquiring original research, assessing it for validity and applying the results are less relevant now that there are robust literature survey services that do this work and provide short, accessible summaries.13 28 A participant explains:
I’m still inundated by journals and articles. So, I’m not going to stop looking at them altogether. But I’m definitely going to spend like two minutes, read the title, glance at the abstract, and read the methods and then I’m not going to feel bad about not reading it and I’m going to just rely more heavily on someone else to do it for me.
Medical decisions involve allocation of resources: Medical decisions for an individual patient do not exist in a vacuum but can affect the community, society and even the same patient at some time in the future.29 Clinicians have a moral and ethical responsibility to decrease wasteful, unnecessary testing and treatment that offer more harm than benefit.29 30
As a participant describes,
The connection to the sort of crisis in healthcare costs is wrong in terms of … the idea that it’s on us, the physicians, making the decision in the room when we are there with the patient and that is where we have control over trying to help the healthcare crisis and healthcare quality in our country. It is morally the right thing to do, and I think that is really what was driving me.
Discussion
In this study, we identified eight concepts delivered in a conference on IM that transformed the worldview of some attendees (box 2). These concepts require participants to restructure their fundamental approach to making patient care decisions, moving from a reliance on pathophysiological, inductive reasoning to practical application of research findings with outcomes that matter to patients. In addition, clinicians embracing this approach must recognise and value the need to continuously and autonomously manage their inventory of medical knowledge. When embraced, this approach thus provides an alternative to relying on the anecdotes or guidance of others and instead cultivates clinicians who feel independent, empowered and possess the ability to continually grow their decision-making skills.31
Transformative concepts of information mastery identified by participants
Theme 1: Uncertainty is an aspect of medical decisions, but steps can be taken to proceed confidently.
Uncertainty plays an integral role in medical practice.
There is a hierarchy of evidence; not all evidence is created equal.
Decisions can be made more confidently if based on patient-oriented evidence that matters (POEMS).
Theme 2: Confidence-making medical decisions requires careful curation of one’s knowledge.
Medical information can be tainted and biased.
Learning how to find information may be more important than learning the information itself.
Curating medical knowledge allows for feeling good about not knowing everything.
Trusted, high-quality information-gathering services should be used instead of attempting to read original research literature.
Medical decisions involve allocation of resources.
Medical practice has entered, with the rest of society, a postmodernist state32 33 that acknowledges there is not a fixed, objective reality that one can define through a careful understanding of pathophysiology. Instead, to embrace an evidence-based approach to decision-making, clinicians must acknowledge the role of uncertainty in medical practice and the necessity of continual curation of one’s knowledge.
The process of an IM approach to medical decision-making—the application of EBM in everyday practice—may thus foster transformative learning experiences with associated affective, behavioural and conceptual change components that alter clinicians’ underlying paradigms and guiding worldviews in medical decision-making.15 34 Further, once grasped, these conceptual underpinnings can be broadly applied in all medical decision-making settings.35
It is possible that there are other themes within IM that were not captured in this study. Gathering more information from a greater number of participants might have identified other types of transformative experiences. This study did not investigate learners who did not cite these eight concepts in helping them approach medical decision-making to understand why the IM approach was less impactful for them.
Conclusions
Because medical decision-making requires a thoughtful, deliberate approach of combining research-based evidence with the clinician’s expertise and the preferences and values of the patient,6 taking an IM approach can potentially support learners in a positive way. IM can help clinicians with the decisions they make based on outcomes that matter to patients, thus enhancing their capacity to embrace lifelong learning while providing high-quality care.
Summary box
What is already known on this subject?
Traditional teaching in medicine focuses on inductive reasoning, moving from pathophysiology to clinical conclusions (what ought to work).
Evidence-based medicine is a deductive reasoning approach, moving from clinical research results to decisions about individual patients (what has been shown to work).
Changing to an evidence-based mode of clinical decision-making by experienced clinicians often results in changes in understanding of the self, revision of belief systems and changes in behaviour, which collectively are termed ‘transformational learning’.
Although a rational and analytical process, this perspective transformation typically has an emotional component.
What are the new findings?
A course in ‘information mastery’, which focuses on teaching clinicians to apply the concepts of evidence-based medicine to make decisions in everyday practice, can induce transformative learning in some participants.
A major theme identified by conference attendees is that uncertainty is an aspect of medical decisions, but steps can be taken to proceed confidently in medical practice if decisions are based on high-quality research on patient-oriented outcomes that matter.
A second theme identified by attendees is that confidence in medical practice requires careful curation of one’s knowledge through understanding that some medical information may not be reliable and that using high-quality information services, instead of attempting to read all the applicable original research literature, is a better means of reducing uncertainty in decision-making.
How might these results change the focus of research or clinical practice?
Teaching of evidence-based medicine needs to account for the shift in worldview that accompanies reliance on critical appraisal of original research to make decisions.
Clinicians who make the switch from making decisions based on pathophysiological reasoning to making decisions based on the best available evidence may have greater confidence despite the inherent uncertainty of medical practice.
Acknowledgments
The authors acknowledge the attendees who agreed to participate in the study. Some of this work previously has been presented at the North American Primary Research Group Meeting, 2018.
References
Footnotes
Contributors All authors were involved in the planning, conduct and reporting of this paper. AFS is the guarantor.
Funding The study was partially funded by the Center for Innovation in Family Medicine.
Competing interests The conference was sponsored by the Tufts Health Care Institute. AFS and DCS have an intellectual interest in the concepts presented during the conference.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent for publication Not required.