Clinical questions stump residents

Most patients can relate to the frustrating experience of sitting in a doctor’s office and waiting for a doctor to answer pressing questions. But it turns out that patients often do not get answers.

A study co-authored by Michael Green, a professor at the Yale School of Medicine, concluded that residents fail to answer a large percentage of patients’ questions. The paper, published earlier this month in Academic Medicine, sets forth eight major barriers — including lack of time, inadequate access to medical information and institutional culture — that reduce residents’ abilities to effectively field questions.

The study, conducted in 2003, focused on a sample of 34 residents affiliated with Yale-New Haven Hospital. The subjects were divided into three focus groups, in which the residents were queried by a facilitator. The information garnered during these focus groups was used to determine the barriers that thwart the residents’ efforts to answer clinical questions.

Green, a specialist in graduate medical education curriculum development, co-authored the study with Tanya Ruff of the University of Michigan Medical School. Green said he had always observed the difficulty residents had in responding to patients’ concerns.

“There is fairly sizeable literature on the topic,” Green said. “Many residents encounter questions very frequently, on a day-to-day basis, and many of them go unanswered.”

He said the barriers generally fall into two categories — technological, or practical, issues and larger, institutional or interpersonal dynamics issues.

On the technical side of things, the results of the study show that residents’ inability to answer questions stems from a lack of easily accessible anecdotal information, as there is no centralized computer database of all data necessary for residents. Many residents simply do not have the requisite skills or familiarity to know how to access available databases, Green said, and there is also a need for more computers where residents see patients.

“Hopefully, the study will draw attention to some of these things and allow hospitals to allocate more money to these areas,” said Paul Tabereaux, a chief resident at Yale-New Haven who participated in the study. “A lot of residents come up to us with questions. There’s a lot of counseling to do.”

Devan Kansagara, another chief resident at the hospital, said many residents could deliver better care if they had experience-based knowledge at their disposal.

“It’s important to look at these barriers and the specific ways they are manifested, and then systematically address them,” he said.

The largest problem for residents, Kansagara said, seems to be that they are unsure how to find answers to their patients’ questions.

The intense work pace could also contribute to the predicament of residents. Residencies, three-year programs for medical school graduates, often demand 80-hour work weeks, and the new doctors see a new patient every 10 to 15 minutes during peak hours, Green said, providing little time to focus on each patient’s individual needs. Residents are responsible for an ever-growing body of medical knowledge, which has increased significantly over the past 20 to 30 years, he said.

Furthermore, the institutional culture of the specific hospital could play a role in residents’ performance.

“One institution might have a greater focus on academics and looking for answers, which could rub off on the residents, while a different institution might work on a more micro-level,” Green said.

He said personal initiative of each individual resident also plays a role in determination and motivation in finding answers.

Green said he hopes the results of his study will lead to the creation of a much-needed Web-based repository of information, which residents could use. He is also presenting the results to health-care officials to alert them to the barriers uncovered by the study and ways these obstacles might be addressed.

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