Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
Department of Medicine, University of California, San Francisco, California, USA.
Med Educ. 2018 Apr;52(4):404-413. doi: 10.1111/medu.13509. Epub 2018 Jan 30.
Transitions of patient care responsibility occur frequently between physicians. Resultant discontinuities make it difficult for physicians to observe clinical outcomes. Little is known about what physicians do to overcome the practical challenges to learning these discontinuities create. This study explored physicians' activities in practice as they sought follow-up information about patients.
Using a constructivist grounded theory approach, semi-structured interviews with 18 internal medicine hospitalist and resident physicians at a single tertiary care academic medical center explored participants' strategies when deliberately conducting follow-up after they transitioned responsibility for patients to other physicians. Following open coding, the authors used activity theory (AT) to explore interactions among the social, cultural and material influences related to follow-up.
The authors identified three themes related to follow-up: (i) keeping lists to track patients, (ii) learning to create tracking systems and (iii) conducting follow-up. Analysis of participants' follow-up processes as an activity system highlighted key tensions in the system and participants' work adaptations. Tension within functionality of electronic health records for keeping lists (tools) to find information about patients' outcomes (object) resulted in using paper lists as workarounds. Tension between paper lists (tools) and protecting patients' health information (rules) led to rule-breaking or abandoning activities of locating information. Finding time to conduct desired follow-up produced tension between this and other activity systems.
In clinical environments characterised by discontinuity, lists of patients served as tools for guiding patient care follow-up. The authors offer four recommendations to address the tensions identified through AT: (i) optimise electronic health record tracking systems to eliminate the need for paper lists; (ii) support physicians' skill development in developing and maintaining tracking systems for follow-up; (iii) dedicate time in physicians' work schedules for conducting follow-up; and (iv) engage physicians and patients in determining guidelines for longitudinal tracking that optimise physicians' learning and respect patients' privacy.
患者的医疗责任经常在医生之间转移。由此产生的不连续使得医生难以观察临床结果。对于医生为克服学习这些不连续性所带来的实际挑战而采取的措施，知之甚少。本研究探讨了医生在实践中寻求患者随访信息时的活动。
采用建构主义扎根理论方法，对一家三级保健学术医疗中心的 18 名内科住院医师和住院医师进行了半结构化访谈，探讨了参与者在将患者的责任转移给其他医生后，有意进行随访时的策略。在进行开放式编码后，作者使用活动理论（AT）来探讨与随访相关的社会、文化和物质影响之间的相互作用。
作者确定了与随访相关的三个主题：（i）保留清单以跟踪患者，（ii）学习创建跟踪系统，以及（iii）进行随访。对参与者的随访过程作为一个活动系统进行分析，突出了系统中的关键紧张关系和参与者的工作适应。电子健康记录（工具）保留信息（对象）的功能与寻找患者结果（对象）的信息之间的紧张关系导致使用纸质清单作为解决方法。纸质清单（工具）和保护患者健康信息（规则）之间的紧张关系导致违反或放弃寻找信息的活动。找到时间进行所需的随访，导致与其他活动系统之间的紧张关系。
在以不连续性为特征的临床环境中，患者清单作为指导患者护理随访的工具。作者通过活动理论提出了四项建议来解决所确定的紧张关系：（i）优化电子健康记录跟踪系统，以消除对纸质清单的需求；（ii）支持医生发展开发和维护跟踪系统进行随访的技能；（iii）在医生的工作计划中专门为进行随访留出时间；（iv）让医生和患者参与确定优化医生学习和尊重患者隐私的纵向跟踪指南。
