The physician's experience of changing clinical practice: a struggle to unlearn
The physician's experience of changing clinical practice: a struggle to unlearn
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DOI：
10.1186/s13012-017-0555-2
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发表时间：
2017-02-28
影响因子：
7.2
通讯作者：
Aron, David C.
中科院分区：
文献类型：
--
作者：
Gupta, Divya M.;Boland, Richard J., Jr.;Aron, David C.
背景资料：改变临床实践是一个困难的过程，证据和实践中的使用之间的时间差以及低价值护理的广泛使用最好地说明了这一点。现有的模型大多侧重于学习和应用新知识的障碍。然而，改变临床实践不仅包括学习新的实践，还包括摒弃旧的和过时的知识。有稀疏的文献关于遗忘发生在医生的水平。我们的研究目标是阐明的经验，试图放弃一个过时的临床实践和它的关系，以学习一个新的one.Methods：我们使用了一个接地理论为基础的定性方法进行我们的研究。我们对克利夫兰退伍军人医疗中心及其诊所的15名初级保健医生进行了30分钟的面对面访谈。结果：研究发现：（1）实务改变会扰乱现状平衡。建立一个新的平衡，采用的变化可能是一个斗争;和（2）的斗争的一部分，建立一个新的平衡，结合实践的变化涉及的“证据”本身和证据和context.Conclusions之间的紧张关系：我们的研究结果提供了证据为基础的支持，许多经验性的遗忘模型，已适应医疗保健。我们的研究结果不同于这些经验模型，因为它们驳斥了以前模型所暗示的静态和单向变化的性质。相反，我们的研究结果表明，临床实践是在不断变化的流动;每一个实例的忘却和学习只是一个标点符号，在这一系列的变化。我们建议修改医生遗忘模型，以反映临床实践不断变化的性质，并证明变化是一个多方向的过程。
Background: Changing clinical practice is a difficult process, best illustrated by the time lag between evidence and use in practice and the extensive use of low-value care. Existing models mostly focus on the barriers to learning and implementing new knowledge. Changing clinical practice, however, includes not only the learning of new practices but also unlearning old and outmoded knowledge. There exists sparse literature regarding the unlearning that takes place at a physician level. Our research objective was to elucidate the experience of trying to abandon an outmoded clinical practice and its relation to learning a new one.Methods: We used a grounded theory-based qualitative approach to conduct our study. We conducted 30-min in-person interviews with 15 primary care physicians at the Cleveland VA Medical Center and its clinics. We used a semi-structured interview guide to standardize the interviews.Results: Our two findings include (1) practice change disturbs the status quo equilibrium. Establishing a new equilibrium that incorporates the change may be a struggle; and (2) part of the struggle to establish a new equilibrium incorporating a practice change involves both the " evidence" itself and tensions between evidence and context.Conclusions: Our findings provide evidence-based support for many of the empirical unlearning models that have been adapted to healthcare. Our findings differ from these empirical models in that they refute the static and unidirectional nature of change that previous models imply. Rather, our findings suggest that clinical practice is in a constant flux of change; each instance of unlearning and learning is merely a punctuation mark in this spectrum of change. We suggest that physician unlearning models be modified to reflect the constantly changing nature of clinical practice and demonstrate that change is a multi-directional process.