On Discontinuity and Learning: Investigations of Physicians' Responses to Transitions of Patient Care Responsibility

Abstract

Physicians routinely transition responsibility for patients to other physicians when they reach the end of work assignments or patients need more or less specialized care. Little is known about the impact of these transitions on learning. When scheduled transitions interrupt the natural clinical reasoning feedback loop, physicians’ may lose opportunities to learn. The overarching goal of this doctoral research was to investigate physicians’ responses to transitions of clinical responsibility. We asked: What motivates physicians to pursue follow-up for previous patients? How do physicians track patients? What factors influence tracking activities? How do physicians react when they find confirming or disconfirming clinical feedback? How do physicians receiving responsibility for patients perceive prior physicians’ receptivity to feedback? How might these perceptions affect feedback delivery? How often and for what reasons do receiving physicians communicate (or not) with prior physicians about transitioned patients in actual practice? We used a constructivist grounded theory approach to explore the phenomenon. We conducted 22 semi-structured interviews with internal medicine hospitalist and resident physicians. Using a critical incident technique (CIT), we elicited transition experiences under two conditions: (1) unfinished clinical reasoning with follow-up revealing others confirmed or disconfirmed provisional diagnoses, and (2) receiving patients in transition and disconfirming others’ diagnoses. Additional questions probed for follow-up strategies, reactions to finding out, resulting practice changes, and communication. For study one, we used motivation as a sensitizing concept to analyze interview data. For study two, we used activity theory to guide data interpretation under the first CIT condition. For study three, we used matrix analysis to analyze CIT cases under the first CIT condition, including emotional reactions and perceived practice changes. For study four, we used a sequential mixed methods design; we analyzed qualitative data from CIT cases under condition 2 to determine factors influencing follow-up communication followed by survey methods to determine associations of these factors with perceptions of receptivity to clinical feedback among 41 hospitalists in two established academic groups. For study five, we conducted structured interviews with 38 hospitalists about communication decisions related to 618 transitioned patients in actual practice. Results: Curiosity about patients’ outcomes determined whether or not follow-up occurred. Clinical uncertainty, personal attachment to patients, and/or concern for patient vulnerability motivated follow-up. Physicians used electronic and paper lists to track patients. Activity theory highlighted tensions and work adaptations for tracking patients. Physicians’ experiences with post-transition clinical feedback were emotionally charged. Physicians receiving transitioned patients were reluctant to provide clinical feedback. Clinical trustworthiness, hierarchy, physical proximity, and time on teaching services associated with perceptions of receptivity to clinical feedback. In practice, communication occurred in 17.3% of cases. Perceptions of prior physicians’ uncertainty and requests for follow-up facilitated communication. Our research provides initial evidence that physicians are intrinsically motivated to overcome discontinuity, adapting patient tracking processes based on environmental constraints. Sending and receiving clinical feedback intended to close-the-loop about patients’ outcomes is a complex, dynamic process influenced by clinical, social, and material factors. This research provides insights that may help address barriers to learning in discontinuous practice environments.