Opening the Black Box: Cognitive Strategies in Family Practice

Robert E. Christensen; Michael D. Fetters; Lee A. Green

doi:10.1370/afm.264

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Figure 1.
Example probe questions used during cognitive task analysis interviews.
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Figure 2.
Sticky note strategy.
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Figure 3.
Model illustrating the dichotomy of expert vs novice decision makers in family medicine.

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Table 1.

Helpers and Detractors of Opportunistic Care

Helpers	Detractors
Note: both lists ranked in decreasing order of frequency of spontaneous mention.
Particular components of the chart	Disorganized, unavailable, or poorly fitting information sources
Organized, up-to-date, and clear records
Patient prompting	Time constraints
Good support from medical assistant	Vague, complex, long, or acute patient complaints
Time
Familiarity with the patient	Other demands on physician
Prompt and reminder system	Patient desire to discuss
Receptive patient	Noncontinuous care
Simple problems	Patient noncompliance
Cues in patient appearance
Physical environment
Recent educational experience
Potential regret

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Table 2.

Variation Among Task-Structuring Strategies

Strategy	Degree of Structure	Primary Source of Information	Key Information Acquisition Point(s)	Mechanism for Conducting Encounter	Management of Encounter	Time Orientation
WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
Sticky note	High	Electronic medical record	Before clinic, beginning of the day, plan is made for the patient encounter based on the chief complaint.	Using sticky note list, previsit plan is instituted	Previsit plan is implemented; sticks to the recorded chief complaint and physician-planned list of issues	Regimented and stays on time
Template	Medium	Written templates	Continuous	Physician maintains binder with management templates based on age, sex, and disease status	Follows anticipated template	Regimented and stays on time
Familiar and fast	Low	Physician memory	During patient encounter from the patient	Mental processing using own memory and input from the patient	Attentional surplus used to address problems of limited nature, reschedule for complex issues	Rapid processing, with flexibility in agenda, but stays on time
Doorstep planning	Medium	Chart	Before patient encounter	Mental tally of agenda is organized	Patient’s complaints are first elicited and than addressed	Clock is a guide, goes over- time if particularly important patient care is needed
			Scan chart outside the examination room
Now or never	Low	All available sources eg, chart, WIC, social worker, clinic nurse, family or friend, etc	Continuous	Iterative list of needs based on information gathered before and during the encounter	Proactive with expectation for comprehensively addressing care needs	Flexible with no time constraints, though time intensive for the patient

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Supplemental Appendix

Supplemental Appendix. Sample interpretative notes from the task diagram

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Supplemental data: Appendix - PDF file, 2 pages, 63 KB
The Article in Brief

This study analyzed the ways in which 18 family physicians make decisions during patient visits. The family physicians used specific, highly individualized, styles for structuring tasks. In addition, features of the decision-making behavior of family physicians were similar to those of expert decision makers in other fields. The authors call for tailoring practice improvement efforts to the different cognitive styles of physicians.