STRENGTHS AND LIMITATIONS OF THIS STUDY

This study employed a grounded theory design, which allowed for a detailed exploration of clinical information-seeking behaviour (CISB).

This is the first known study to identify dimensions, strategies and determinants of the physicians’ CISB at the point-of-care questions.

This research addresses the CISB process as an interactive, dynamic, non-linear and a multidimensional phenomenon while dealing with clinical questions.

Like many qualitative studies, the generalisability of the findings may be limited.

Introduction

In recent years, physicians have encountered numerous challenges concerning the accessibility of pertinent information. These challenges encompass accelerated changes in clinical knowledge, information overload, the growing complexity of care and ongoing innovations in the field. Researchers have advocated for the utilisation of the best available evidence in health-related decision-making by all healthcare professionals as a means to address these challenges.1 2 Additionally, several studies have demonstrated that using such resources can effectively address clinical inquiries and enhance physicians’ performance.3–7

Despite the emphasis on evidence-based medicine (EBM), physicians have not consistently integrated EBM tools into their daily medical practices,8–10 as indicated by several studies. Furthermore, there is a lack of proficiency among physicians in evaluating evidence effectively.11 12 Additionally, research suggests that physicians only seek answers to approximately half of the clinical questions that arise during patient care and are able to find solutions to only a fraction of these inquiries.13 Despite the availability of electronic medical records (EMR) and decision support systems, their design and implementation have encountered numerous challenges.14–17 The learning EMR (LEMR) system aims to address these issues by leveraging physicians’ information-seeking behaviour (ISB) model to enhance data presentation for upcoming patients.18 These identified deficiencies underscore the importance of identifying and understanding the clinical ISB (CISB) process.

Numerous studies have examined various aspects of CISB among physicians, including their information needs, used resources, frequency of posed questions, as well as barriers and facilitators.13 19–23 While many of these studies have outlined the procedural aspects of CISB, few have delved into the specific activities, determinants and decision-making processes involved. Hung et al 24 introduced a hierarchical multilevel model of context-initiated information aimed at enhancing the representation of human search expertise. Similarly, Cook et al 15 employed grounded theory to characterise the barriers and decision-making processes associated with responding to clinical questions. King et al 18 argued that EMR systems should integrate the ISB model to mitigate cognitive overload by presenting relevant information to individual patients in a timely manner.

However, the existing literature highlights a lack of comprehensive investigation into the CISB and only a few studies have delved into determinants and CISB processes. This gap in the existing research could lead to an incomplete understanding of the CISB process, which could ultimately result in less effective medical tools. If we do not know how physicians search for information, we cannot optimise decision support systems to respond to their information needs. To address these deficiencies and improve the CISB process, we need a deeper understanding of its theoretical foundations including the activities, determinants and decision-making processes involved in CISB. This understanding could help better comprehend to enhance medical systems to meet physicians’ information needs and ultimately contribute to providing better care for patients.

On the other hand, considering that ISB is heavily influenced by context and impacting factors, therefore, the CISB of physicians needs to be deeply studied in all aspects. Given that grounded theory, by delving into the phenomenon, seeks to discover existing interactions and social processes beyond describing what is said and observed in phenomena and focuses on processing and presenting theory, it can help identify dimensions, conditions, interactions, processes and motivations of the process. Therefore, the current study aimed to explore the dimensions, interactions, strategies and determinants of CISB among physicians in the clinical setting. To achieve this objective, the following subgoals were addressed:

Identifying the causal conditions affecting the CISB of physicians.

Identifying the contextual conditions affecting the CISB of physicians.

Identifying the intervening conditions affecting the CISB of physicians.

Identifying the action/interaction strategies adopted by physicians in CISB.

Identifying the consequences that originated after the CISB of physicians.

Materials and methods

A qualitative study was undertaken using the grounded theory approach, chosen for its capacity to foster the development of theory grounded in data through concurrent and systematic data collection and analysis.25 This methodology was selected due to the absence of existing theoretical frameworks concerning the subject matter.26 Grounded theory is well suited for elucidating phenomena within their contextual framework25 27 and has been successfully applied in explaining ISB.26 28

The setting, participants and study design

The study was conducted from April 2018 to June 2020 at academic centres affiliated with Isfahan University of Medical Sciences (IUMS), which comprises 11 academic hospitals in Isfahan, including tertiary referral hospitals. Participants consisted of 12 specialists and nine subspecialists, meeting 2 specific criteria. First, participants were required to attest to the use of EBM tools in their clinical practice, as evidenced by self-declaration and endorsement from the vice-chancellor for education or research. Second, participants were mandated to have authored at least one research paper in their respective fields, either as the first author or corresponding author.

Purposive sampling was initially used for the selection of participants in the interviews. Subsequently, as codes and themes began to emerge, theoretical sampling was employed to gather the necessary data. The process of participant selection, data collection and analysis continued until theoretical saturation was achieved. Saturation was attained after the 18th interview, whereby no new codes emerged. However, interviews were conducted with a total of 21 participants to ensure comprehensive data collection.

Interview guide

The researcher (AD) conducted in-depth, one-on-one interviews using a semistructured interview guide. Interviews were held face to face in the wards and clinics. Each interview session lasted for 45–60 min. The process was audio recorded with the consent of participants. This interview guide (online supplemental file 1) was developed through discussions with team members, informal conversations with physicians and librarians, and a review of prior studies on CISB.15 29–31 During the interviews, probing questions were employed to elucidate information and gather supplementary data.

Qualitative analysis

The interviews were recorded in their entirety, transcribed and subsequently reviewed and approved by the participating individuals. Data analysis was conducted using Strauss and Corbin’s grounded theory approach,25 encompassing open coding, axial coding and selective coding. Additionally, the constant comparative approach, theoretical sensitivity and memoing were employed throughout each stage of analysis to facilitate theory development. Data collection and analysis were conducted concurrently. Various software tools were used for qualitative data analysis, including Microsoft Word and MAXQDA V.10.

During the open coding phase, three researchers (AD, HA-R and AZ-B) independently scrutinised the three texts (participant specialty, year of experience: emergency medicine, 8; ear, nose and throat, 27; general surgery, 7) line-by-line, extracting related concepts and keywords. This process was conducted iteratively, resulting in the identification of 344 concepts. Discrepancies in coding were resolved through discussion with other investigators (MS and RK). Also, the text of several interviews, codes and extracted categories were made available to a number of experts in the qualitative research who did not participate in the study, to review and ensure that the initial codes were derived from the interview content and not the interpretations or preconceptions of the researchers. Furthermore, the extracted categories and concepts from the interviews were also shared with some of the participants to ensure that their intended meaning was reflected in the results.

Subsequently, these initial codes were synthesised into 70 concepts through multiple revisions based on shared characteristics. During the axial coding stage, all interviews were systematically coded. Subsequently, the research team (which are experts in the qualitative researches) collaboratively consolidated these codes into 25 subthemes through consensus. Connections were established between these subthemes and various elements such as causal conditions, intervening and contextual factors, strategies and consequences. Finally, through selective coding, seven principal themes were synthesised into a core category, forming the foundation of the principal theoretical framework.

The researchers ensured trustworthiness by engaging in detailed transcription and description of methods, systematic planning and coding following Lincoln and Guba guidelines.32 33 Additionally, the research followed the Consolidated Criteria for Reporting Qualitative Research reporting guideline34 (online supplemental file 2).

Patient and public involvement

None.

Results

As depicted in table 1, a total of 21 physicians from educational-medical centres partook in the interviews. The participants ranged in age from 35 to 57 years and possessed clinical experience spanning from 2 to 30 years. The analysis yielded 7 principal themes and 25 subthemes.

Table 1

Characteristics of participants

Theme 1: clinical information needsSubtheme 1: diagnostics

Physicians expressed the view that prompt and accurate diagnosis is imperative for resolving clinical issues. They identified numerous questions surrounding paraclinics, differential diagnosis, atypical presentations of illnesses and the utilisation of minimally invasive diagnostic methods.

Subtheme 2: treatment

Following diagnosis, physicians emphasised the importance of accessing clinical information to meet their needs pertaining to medical and surgical treatments, disease management and pharmacotherapy.

Subtheme 3: updating clinical information

Physicians expressed the necessity of acquiring clinical information to facilitate ongoing training and skills development, ensuring adherence to treatment standards, staying abreast of the latest scientific advancements and recognising emerging treatment protocols (refer to table 2 for supporting quotes).

Table 2

Example quotations illustrating the themes

Theme 2: clinical question characteristicsSubtheme 1: question complexity

Physicians perceive questions as straightforward when they relate to simple illnesses, allowing straightforward research to provide answers. Conversely, complex questions arise from intricate and multisystemic diseases, feature complicated clinical presentations and involve multiple bodily organs.

Subtheme 2: question significance

Significant questions are paramount, as leaving them unanswered can lead to numerous challenges and severe complications for the patient. In contrast, less significant questions typically pose minimal risk to the patient. For example, seeking new information to enhance personal knowledge is a question used in this area.

Subtheme 3: the question originated from the involvement duration

Physicians noted that the physician’s intermittent and long-term engagement with outpatient or inpatient care influenced their ISB. Short-term involvement typically occurred in outpatient settings and during patient follow-up programmes, while prolonged engagement was observed in inpatient care or cases where patients did not respond to treatment. Importantly, extended durations of involvement were perceived as conducive to acquiring clinical information (refer to table 2 for supporting quotes).

Theme 3: information usabilitySubtheme 1: service accessibility

Physicians reported having quick, easy and convenient access to resources facilitated by Wi-Fi, virtual private network connections to various databases and the availability of personal digital assistants, computers and other technical equipment related to the internet within medical centre departments.

Subtheme 2: resource accessibility

Physicians emphasised that resources with the highest accessibility were in high demand. They highlighted the importance of resource diversity, including access to databases containing articles, books, educational videos and images. Moreover, they underscored that comprehensiveness, coverage, access to full-text materials and availability of free information resources were essential facilitators of clinical decision-making.

Subtheme 3: physician capability

Physicians identified sufficient information-seeking skills and proficiency in English, as the global language of science, as facilitators of CISB. However, they emphasised that the most significant barriers to clinical information seeking were the lack of time and workload overload. These circumstances often resulted in physicians being unable or uninterested in fulfilling their information needs (refer to table 2 for supporting quotes).

Theme 4: clinical information resourcesSubtheme 1: personal information resources

Physicians typically rely on personal information resources to address clinical inquiries, primarily due to their prompt accessibility and perceived reliability. Colleagues within the same specialty often serve as advisors during the final decision-making process for implementing specific care. Additionally, specialists from diverse fields are often consulted to manage complex diseases involving multiple organs.

Subtheme 2: interpersonal information resources

Physicians identified the latest editions of textbooks and guidelines used by physicians as their primary and secondary sources of information, respectively, owing to their authenticity. Medical databases, comprising contemporary diagnostic, therapeutic and disease management techniques, were cited as the third source of information. Additionally, physicians mentioned academic websites, medical associations, Google and social media platforms such as YouTube, which featured educational materials on therapy and surgical protocols (refer to table 2 for supporting quotes).

Theme 5: factors influencing information seekingSubtheme 1: personal factors

Physician motivation was identified as a crucial factor influencing information needs. Professional dedication compels physicians to resort to information-seeking as a problem-solving approach in complex situations. Physicians emphasised that an inherent spirit of inquiry fosters curiosity when confronted with clinical questions, driving them to seek answers. Moreover, attending teaching and referral centres was cited as a motivating factor for physicians to seek information about the unknown.

Subtheme 2: organisational factors

Education and empowerment initiatives regarding information retrieval, access to educational and research equipment, facilities and dedicated physical spaces within clinical settings play a crucial role in enabling physicians to seek clinical information actively. However, the inadequate assessment of faculty members’ medical and educational contributions compared with their research endeavours highlights the absence of an effective evaluation system to measure these activities qualitatively. Moreover, the current assessment system fails to differentiate between physicians who use EBM principles and those who do not. An evidence-based framework must be integrated into all aspects of the healthcare system to assist healthcare providers in leveraging the most credible evidence in their decision-making processes.

Subtheme 3: technical factors

Physicians emphasised the importance of a user-friendly system, stating that it facilitates ease of learning and retention of usage procedures. Additionally, such a system streamlines uncomplicated tasks, eliminating the need for lengthy processes. Furthermore, physicians highlighted the system’s extensive search capabilities and its ability to cater to individual search preferences, competencies and skills. Moreover, the system’s capability to categorise information into distinct classes enables users to extract relevant data without confusion. Consequently, this type of system is deemed suitable for physicians with busy schedules who may not have the time to seek information or actively acquire related skills.

In general, information and communication technology infrastructure can create a conducive environment for physicians’ communication and access to information. However, it is crucial to acknowledge that domestic Internet filtering systems, which restrict access to services such as YouTube, and international bans on purchasing certain information resources can exacerbate disinterest in using such resources.

Subtheme 4: social factors

Physicians expressed the belief that public awareness and societal pressures could influence physicians’ interests, judgements and decisions regarding information-seeking. Heightened public awareness was seen as increasing the need for accurate information. In instances of medical errors, the media’s scrutiny could exert pressure on physicians, motivating them to prevent such occurrences by seeking the most authentic and reliable evidence (refer to table 3 for supporting quotes).

Table 3

Example quotations illustrating the themes

Theme 6: action/interaction encountering clinical questionsSubtheme 1: type of action

Focused attention on addressing clinical questions and meeting information needs empowers physicians to either take action or refrain from engaging in ISB. Physicians who choose to take action actively seek information to resolve clinical issues consciously and intentionally. Conversely, opting not to engage in ISB occurs in various scenarios, such as when physicians believe the question has no solution, lack access to information sources, rely on existing knowledge to address the problem or perceive the case severity as too high. Additionally, physicians may refrain from seeking information due to feelings of inadequacy in overcoming challenges or concerns about legal repercussions. In such situations, physicians may rely on existing knowledge or refer the patient to another healthcare provider.

Subtheme 2: action strategy

The strategy of taking action can vary in terms of explicitness, frequency and timing of occurrence. Physicians typically exhibit explicit behaviour when seeking information. Still, they may adopt a more conservative approach if they fear jeopardising their current position, particularly if they possess extensive experience or are older. When faced with less authentic information sources or when dealing with significant, critical or complex problems, physicians tend to seek information from multiple sources. In cases where the clinical question is straightforward, and the information source is highly reliable, physicians actively engage in ISB. Moreover, if there is a risk of patient harm due to a delay in finding an answer to a question, physicians promptly seek information. Additionally, when physicians are unable to gather sufficient information from available sources or when the question pertains to updating knowledge, they engage in postponed ISB.

Subtheme 3: action evaluation

After retrieving information, physicians evaluate their actions by assessing the relevance, credibility and updatability of the obtained data. Physicians described relevance as the extent to which the retrieved results aligned with their information needs, often gauged through comparison with their prior knowledge. Additionally, physicians scrutinised various factors such as the research content, journal, author and affiliations of research-supporting institutes to assess credibility. Using less authentic resources could potentially complicate patient care and expose physicians to legal liabilities. Furthermore, physicians considered the publication and research dates to evaluate the currency of the information, as lengthy printing and publishing processes could render the data obsolete.

Subtheme 4: action feasibility

Following the evaluation process, physicians assess the feasibility of their actions, considering various factors such as the cost-effectiveness of diagnostic and treatment procedures, availability of hospital equipment, patient preferences, financial constraints and potential legal implications. Physicians prioritise diagnostic and therapeutic approaches that are highly cost-effective for both the patient and the healthcare system. Adequate medical equipment is crucial for patient care in medical centres, facilitating diagnosis and treatment. Physicians emphasised the importance of recognising each patient’s unique needs, abilities, values and beliefs. Moreover, they emphasised respecting patients’ rights to choose services based on their preferences and financial circumstances. Finally, physicians assess their ability to deliver the prescribed care procedures, ensuring they will not encounter legal challenges. Physicians need to be prepared to defend the chosen diagnostic or therapeutic approach in this regard.

Subtheme 5: action selection

The physician assesses whether the obtained information adequately meets the information needs. If deemed insufficient, the information-seeking process is repeated until sufficient information is acquired. Evaluation of information is reiterated at this stage, given the significance of the issue for the patient and the potential legal implications for the physician.

Subtheme 6: clinical decision

Clinical decision-making is paramount during the information-seeking stage, as physicians bear responsibility for care-related outcomes. In this context, physicians make clinical decisions either at once or continuously. Immediate decisions typically address simple and less urgent questions or the need for information renewal. Conversely, continuous decision-making is common in cases involving patients with complex, multisystemic or rare diseases. The decision-making process may be revisited and altered based on the physician’s acquired information and consultation received.

Subtheme 7: action management

At the conclusion of the strategy, physicians save and share data acquired during the information-seeking process. If relevant and appropriate information is obtained, physicians store it for future reference using information management software. Moreover, sharing information serves to enhance knowledge and raise awareness among colleagues and students (refer to table 4 for supporting quotes).

Table 4

Example quotations illustrating the themes

Theme 7: CISB consequencesSubtheme 1: patient-related consequences

The most significant achievement of CISB for a physician lies in the concepts of patient recovery and satisfaction. Patient recovery stands as the ultimate goal of any physician, while patient satisfaction is intertwined with the process of recovery. It hinges not only on the successful resolution of the disease but also on minimising financial and time burdens for the patient.

Subtheme 2: physician-related consequences

Personal development is a direct outcome of information-seeking for physicians. Through this process, physicians can discern and enhance their strengths and weaknesses, talents, abilities and skills. Moreover, physicians attain professional growth by acquiring knowledge, identifying gaps in knowledge and actively seeking to expand their expertise. Engaging in CISB facilitates self-actualisation, enabling physicians to achieve happiness and self-satisfaction. Furthermore, successfully completing tasks through CISB enhances physicians’ self-confidence.

Subtheme 3: organisation-related consequences

Organisational achievement through the effective utilisation of CISB fosters synergy and promotes the organisation’s growth and development. It contributes to reducing medical errors and avoiding financial waste, ultimately leading to financial benefits. Moreover, organisational credibility encourages the regular and continuous referral of patients, giving the organisation a competitive edge. Establishing a strong organisational reputation and brand identity further enhances organisational authority in medical centres, attracting more customers (refer to table 4 for supporting quotes).

Discussion

This paper aimed to investigate the clinical information-seeking process at the point of care, identifying seven key themes: clinical information needs and characteristics of clinical questions (causal conditions), information usability (interfering conditions), clinical information resources as factors influencing information-seeking (context conditions), action/interaction when encountering clinical questions (strategies) and consequences of CISB (consequences). The CISB model depicted in figure 1 reflects an interactive, dynamic and non-linear process.

Figure 1

Clinical information seeking behaviour model.

As outlined by Foster,35 non-linear models deviate from linear information-seeking models. Similarly, in the physician’s CISB model, the starting and ending points are not fixed, and the information-seeking process may persist by addressing causal, contextual and intervening conditions. This process can be iterated with a feedback loop or transition to another process altogether.

In the present study, the theoretical explanation revealed that CISB occurred in demanding clinical scenarios encompassing diagnosis, treatment and information updating. Previous studies have acknowledged diagnosis and treatment as primary or secondary types of information needs in clinical settings.23 29 36–43 Unlike findings from Cook’s research,15 patient education did not emerge as a motive for information-seeking in the present study. This discrepancy may be attributed to the physicians’ heavy workload.

The physician’s causal factors shaping the CISB process include characteristics of complexity, the significance of the question and the duration of the physician’s involvement with the patient. Moreover, variations in mental analysis and focused attention on solving clinical problems (core category) influence changes in the CISB process. Physicians encounter the most significant changes when confronted with urgent, complicated and critical questions for which they have access to information to provide answers. Some studies have highlighted low significance as a reason for unanswered questions in clinical practice,42 44–46 while the urgency of the question has been identified as a motivation for seeking information.19 47 These findings align with the outcomes of the present study.

Resource usability serves as an intervening condition that either facilitates or constrains CISB. The following factors are identified as enhancing physicians’ accessibility to information: access to technical services,48 49 optimal internet speed in clinical settings,12 50–52 completeness of information,53 immediate access to resources15 54 and considerations regarding information resource costs.39 55

Various factors influence the contextual formation of the CISB process among physicians, encompassing clinical information resources as well as personal, organisational, technical and social factors. These factors can either strengthen or detract from the focus on resolving clinical issues. Textbooks3 42 45 49 56–67 and guidelines64 66 68 69 are frequently used due to their high credibility. Additionally, Google is employed for its accessibility to a wide range of information resources.62 70 However, physicians typically do not rely on Google for clinical judgement; instead, they use Google as an initial step in the CISB process to verify the accuracy of information obtained from other sources.

In general, causal, intervening and contextual conditions enable physicians to focus on resolving clinical problems and guide them in selecting appropriate information-seeking strategies. The strategies adopted by physicians in CISB form the core of the theory. The model developed by Cook et al 15 aligns well with the model extracted in the present study. This study categorises some of these factors into barriers and enablers. However, the weakness of these classifications lies in their broadness and the lack of classification of factors as contextual or intervening. Indeed, many of these factors contribute to the contexts and conditions for information-seeking, while others directly facilitate or limit the strategy in question.

When physicians encounter challenging clinical problems, focused attention enables them to decide whether to engage in ISB. If they choose not to seek information directly, they may opt to refer the patient to a colleague, using deferral as a decision-making strategy.56 71 However, if physicians decide to seek information, their action strategy is determined by factors such as explicitness, frequency and timing. Following the retrieval of information, physicians evaluate their actions through a process of action evaluation. During this phase, physicians assess the obtained information for relevance, credibility and updatability. Veinot et al 72 demonstrated that information evaluation encompasses considerations such as usefulness, relevance, validity and value.

When physicians access highly valid information, they consider the feasibility of action, which is determined by the physician’s reflection on the cost-effectiveness of diagnostic and therapeutic methods, availability of hospital equipment, patient preferences and financial resources, with no potential legal complications. In the action selection stage, physicians initially assess the sufficiency of information and, if necessary, make clinical decisions. Subsequently, physicians manage the action by sharing and saving information. If physicians find that their mental standards are not met, they may revisit previous stages or even the beginning of the process to start anew. The strategies employed in this process are inherently recursive, allowing for the creation of new information-seeking paths after addressing the initial need. Furthermore, the nature of feedback is inherent at each stage of the process.

Numerous studies have highlighted that CISB among physicians leads to improvements in patient care.37 73 74 In the present study, physicians’ adoption of CISB strategies not only facilitated personal and professional growth and self-actualisation but also contributed to enhanced organisational performance and authority. Moreover, these strategies positively impacted patient satisfaction and recovery.

Study strengths and limitations

In the present study, data analysis was conducted using a rigorous theoretical approach, resulting in an interactive, dynamic and non-linear model. Furthermore, all strategies identified are inherently recursive. This model offers a theoretical foundation that enhances understanding of CISB during patient care, achieved through the classification of causal, contextual and intervening factors and strategies. This research contributes to the development of a formal and comprehensive theory by advancing interdisciplinary understanding. Like many qualitative studies, the generalisability of the findings may be limited. However, adherence to conditions ensuring data accuracy can enhance the generalisability of the results to related contexts.

Conclusions

The information-seeking process commences with the identification of an information need and is directed towards resolving clinical issues. The CISB process follows an IF-THEN sequence when addressing clinical problems. In the presence of stimuli such as information needs and suitable characteristics of the clinical question, and under facilitating contextual and intervening conditions, physicians are directed towards professional and organisational growth. Additionally, they enhance patient satisfaction by adopting information-seeking strategies and focusing on resolving clinical issues. Conversely, if the necessary stimuli are insufficient, physicians are directed towards a failure to seek information. Consequently, the rhythm of the physician’s CISB process aligns with variations in the characteristics of the clinical problem and contextual conditions, encompassing individual, organisational, technical, social and resource usability factors.

The findings highlight that CISB is a multidimensional phenomenon. Understanding CISB aids managers, policy-makers, clinical librarians and information system designers in effectively implementing various interventions, such as appropriate training methods and the enhancement of monitoring and evaluation systems, to promote focused attention on clinical problems and CISB among physicians. Additionally, the CISB model can serve as a theoretical foundation for the development of clinical decision support systems, electronic health record and EMR systems.

Data availability statement

Data are available on reasonable request.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and it was reviewed and approved by the research ethics board of IUMS (No. IR.MUI.REC.1396.3.524). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We thank all research participants in the academic centres of Isfahan University of Medical Sciences.