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A DESCRIPTION OF PHYSICIANS' PRACTICE BEHAVIORS AND
LEARNING ACTIVITIES ASSOCIATED WITH CHANGES

MADE IN A PRIVATE MEDICAL PRACTICE

BY

Robert J. Long

A DISSERTATION

Submitted to

Michigan State University
in partial fulfillment of the requirements

for the degree of

DOCTOR OF PHILOSOPHY

Department of Administration and Higher Education

1986

Copyright by
Robert J. Long
1986

ABSTRACT

A DESCRIPTION OF PHYSICIANS' PRACTICE BEHAVIORS AND
LEARNING ACTIVITIES ASSOCIATED WITH CHANGES
MADE IN A PRIVATE MEDICAL PRACTICE

BY

Robert J. Long

This study has resulted in a description of the role
that change and its associated learning activities play in
physicians' private medical practices. Grounded research
methoaology provided the conceptual framework for
structuring and carrying out the study. Semistructured
interviews were conducted with two specialty groups which
included nine obstetrician/gynecologists and eleven
internists. The following areas of investigation were
included in the study: identifying the various types of
changes which occur in practice; identifying learning
activities related to a private medical practice; and
describing, indepth, specific changes and their associated
learning activities.

The findings of this study indicate that physicians'
change behavior and associated learning activities are an
integral component of a physician's practice behavior and

should be viewed as an essential part of the determining

elements which define the boundaries of a private medical
practice. These elements include the scope or extent of the
medical field encompassing the practice, the depth of
knowledge and training within each area of practice, and how
close to the frontier of knowledge or cutting edge the
physician practices. Many influencing factors control these
elements, among them are competition, peer pressure,
medical-legal concerns, social pressure, physicians' own
psychological needs, and economic considerations.
Physicians' change behavior and associated learning
aetivities should be viewed as an integral component of
these three determining elements, routinized in the very
nature of a private medical practice. Hence, individual
instances of physicians' change and learning behaviors are
best conceptualized as a part of a broader practice behavior
pattern rather than a separate developmental process

impacting on a private medical practice.

DEDICATION

To my wife Valeria whose encouragement and

assistance has been so important in this effort.

Be like a bird who

Halting in his flight

On a limb too slight

Feels it give way beneath him,
Yet sings,

Knowing he has wings.

Victor Hugo

ii

ACKNOWLEDGMENTS

I would like to extend my deepest thanks and
appreciation to my advisor and dissertation director Robert
K. Richards, who has been kind, nurturing, and
understanding. I am indebted to his thoughtful
consideration of my personal and professional development.
Thanks also go to the other members of my committee,
Benjamin A. Bohnhorst, Louis F. Hekhius, and S. Joseph
Levine, who each in their own way have helped me grow as a
learner.

I would also like to thank John C. Peirce for his
assistance and_interest in my studies.

Also I would like to thank the many family members,
friends, and colleagues who have supported and encouraged my
efforts.

Lastly, many thanks must be extended to those
physicians who volunteered their time and efforts for this

study.

iii

TABLE OF CONTENTS

DEFINITION OF TERMS . . . . . . . . . . . . .

Chapter I
INTRODUCTION . . . . . . . . . . . . . .
Problem Area

Purpose . . .
Methodology .

Assumptions
Limitations
Significance of the Study
The Remainder of the Study

Chapter II
REVIEW OF THE LITERATURE . . . . . . . .

The Adult Learner . . .
The Self— Directed Adult Learner
Making Changes . . . . . . . . .
Adults Pursuing Education . . .
How Adults Learn . . . . .
Influence of Aging on the Adult

Learner . . . . . . .

The Communication Process
The Innovation . . . .
Communication Channels
Time 0 O O O O O O 0
The Social System . . .

The Innovation-Decision Proces
Support for Stages in the

Innovation-Decision Process . .

S

Rogers' Innovation-Decision Process

Model . . . . . . . . . . . . .

The Process of Biomedical Innovation

Biomedical Innovation Models . . .

The Coleman Study . . . . . . . .

The Geertsma Study . . . . . . . .
Sources of Information and

Communication Channels . . . . .

iv

Page

24

24
25
27

30

33
34
35

38
39
40

40

41
43
44
47
52

55

Page
Information Acquisition and
Utilization O O O O O O O O 0 O O O O 57
summary 0 O O O O O O O 0 O O O O O O O 59
Chapter III

METHODOLWY O I I O O O O O O O O O O O O O O O 61

Introduction . . . . . . . . . . . . 61
Grounded Research Theory . . . . . . . . . 62
Orienting Concept . . . . . . . . . . . . 63
Theoretical Sampling . . . . . . . . . . 63
Comparative Analysis . . . . . . . . . . 65
Theoretical Saturation . . . . . . . . . 66
Coding and Data Analysis . . . . . . . . 67
Nature of Grounded Theory . . . . . . . . 68
The Interview . . . . . . . . . . . . . . . 70
Backgrounds, Personalities and
Behaviors, and Roles . . . . . . . . . 72
Facilitators and Inhibitors of
Communication . . . . . . . . . . . . . 75
Interview Strategies, Techniques
and Tactics . . . . . . . . . . . 77
Reliability and Validity . . . . . . . . 81
Methodology for this Study . . . . . . . . . 82
The Researcher . . . . . . . . . . . . . 82
The Setting . . . . . . . . . . . . . . . 84
The Study Population . . . . . . . . . . 84
Identifying the Study Population . . . . 85
Interview Format . . . . . . . . . . . . 88
Development of the Interview Format . . . 90
Interview Follow-up . . . . . . . . . . . 101
Handling the Data . . . . . . . . . . . 103
Reliability and Validity . . . . . . . . 103

CHAPTER IV
FINDINGS AND DISCUSSION . . . . . . . . . . . . 105

Introduction . . . . . . . . . . . . . . 105
The Obstetrics/ Gynecology Interviews . . . . 106
Obstetrics/Gynecology Resource
Physician . . . . . . . . . . . . . . . 106
The First Interview . . . . . . . . . . . 108
Obstetrics/Gynecology Interviews--
First Component . . . . . . . . . . . . 111
Obstetrics/Gynecology Interviews--
Second Component . . . . . . . . . . . . 119

Obstetrics/Gynecology Interviews--
Third Component . . . . . . . .
The Internal Medicine Interviews . .
The Internal Medicine Resource
Physician . . . . . . . . . . .
Internal Medicine Interviews--
First Component . . . . . . . .
Internal Medicine Interviews--
Second Component . . . . . . . .
Internal Medicine Interview--
Third Component . . . . . . . .

CHAPTER V
CONCLUSIONS AND IMPLICATIONS . . . . .

Methodology . . . . . . . . . . . .
Physicians' Practice Behavior . . . .
Practice Behavior Paradigm . .
The Role of Learning in a Physician
Practice . . . . . . . . . . .
Learning Associated with Making
Changes in a Practice . . .
Implications . . . . . . . . .
Methodology . . . . . . . . .
Application . . . . . . . .
Topics for Further Research .

APPENDICES
A. ROGERS ' CHANGE MODEL 0 O O O C O O O

. PHYSICIAN PROFILE . . . . . . . . .

. LETTER OF INVITATION . . . . . . . .

B
C
D. SECOND LETTER . . . . . . . . . . .
E. INTERVIEW OUTLINE . . . . . . . . .
F. POST-INTERVIEW FIELD NOTES . . . . .
G. TRANSCRIPTION FORMAT . . . . . . . .
H. THANK YOU LETTER . . . . . . . . . .

BIBLIOGMPHY O O O O O O O O O O O O I O O 0

vi

Page
126
128
130
131
143
146

153
153
155
156
162
166
172
172

173
174

176
177
178
179
180
183
184
186
187

DEFIN ITION OF TERMS

E E' 'I' E T

The following terms are defined to assure clarity in
this study:

Agafigmd§_mgdiging - The practice of medicine associated with
a university or research facility.

— Axford (1980, p. 2) defines adult learning
as "planned and organized learning activities chosen on
either a formal or informal basis with the conscious
intention of self-fulfillment, including information
seeking, understanding, skill acquisition, and identifying
and solving personal and community problems.“

Adoption - Adoption is a decision to begin full use of an
innovation.

- “The art and science of helping maturing adults
learn." (Knowles, 1975, p. 19).

- A private practice physician who has
admitting privileges at a hospital.

Bigmgfii;al_fi§1d - All activities centered around the
science of medicine including clinical practice and

research.

- Generation and diffusion of
a biomedical technology into medical practice.

andinlngifit - Subspecialist concerned with the diagnosis
and treatment of the heart.

Changssagsnt - One whose purpose is to influence others'
deciSiuns to change.

Changg_mgdg1 - A sequence of cognitive steps involved in the
incorporation of a change in ones behavior.

WWW - Types of changes physicians
experience in their practice, grouped into eight areas.
(Geertsma, 1982)

ClinicaIngpgrienge - Those learning activities which occur

in an environment where medicine is being practiced.

Cading - Process of isolating the data into individual
indices or concepts and reorganizing them into conceptual
categories.

2
Colloagno - An associate in a profession.

Communioation - ”A process in which participants create and
share information with one another in order to reach a
mutual understanding.” (Rogers, 1983, p. 5)

£ommoniootion_ohannol - The means by which a message gets

from a source to a receiver.

QQEPBIIEQD_QLQMDS - Group of subjects viewed in relation to
another group of subjects.

.535 - That part of the theoretical sampling
strategy that involves the systematic choice and study of
several comparison groups.

Conceptual.catsgories - Groupings of data into common areas

from which general concepts can be derived.

Consultation - A deliberation between physicians on a case
or its treatment.

' 1;.oooootion - An organized, formal attempt to
teach adults.

Cosmonolito - An outlook which extends beyond the immediate
environment.

Cross_tr§ot,transfior — Transfer of an innovation to a

completely different unrelated purpose.

— "Performance in which skilled
judgment habits have become crystalized (whence its name) as
the result of earlier application of some prior, more
fundamental general ability to these fields." (Cattell,
1963) ‘

Cot;ing_odgo - Frontier of knowledge, having possession of
the most up-to-date information in an area.

Dodootixo_1ogio - Method of thinking where conclusions
follow necessarily from the premises.

D£2Lh.9fi.9£fl££i££ - Level of expertise within any area of
medicine.

WW - Different frames of

reference for responding to and learning from one's daily
experiences.

- Both external actions and internal
thinking associated with adapting to life's changing
circumstances.

3

Dioootio_iooiuio,- Systematic instruction through teachings.

Diffusion - The process by which an innovation spreads.

thooordiogioony - Sonographic study of the heart and its
function.

Eiuio_inioiiigonoo - ”Perceiving relations, educing
correlates, and maintaining span of immediate awareness in
concept formation and attainment, reasoning and
abstuacting." (Horn, 1968)

£oxmol_ihoory - Conceptual theory developed from various
empirical areas. This transcends substantive areas.

fixounood_1osoaion - A method of developing theories,

concepts and hypothesis from data which are systematically
obtained and analyzed.

Erouooorootioo - Two or more physicians practicing medicine
in a partnersnip or corporation.

- Branch of medicine which treats diseases of the
genital tract in women.

‘ - - Businesses that produce the tools
used in the practice of medicine.

- Branch of medicine which treats morphology of
the blood and blood tissue.

Boioxoohiious - Interpersonal communication between
individuals who are not alike.

- Interpersonal communication between
individuals who are alike.

flouso,§taff - Interns and residents (physicians in a
training program) employed by a hospital.

Induotixo_iogio - Act of reasoning from a part to a whole or
from particulars to generals.

Innoyation - ”An idea, practice, or object that is perceived
as new by an individual or other unit of adaption."
(Rogers, 1983, p. 11)

innooatois — Early adopters, those who adopt an innovation
before most of their peers.

.oisonai_notuonks - Communication channels between

individuals.

4

- ' ' - Rogers (1983, p. 20) defines
this as "a process through which an individual (or other
deCiSiun-making unit) passes from first knowledge of an
innovation, to forming an attitude toward the innovation, to
a deciSiun to adopt or reject, to implementation of the new
idea and to confirmation of this decision."

— Those changes that occur when a person
clearly chooses a particular change and takes steps to
achieve it.

inguinis; - A physician who specializes in the diagnosis and
medical, as opposed to surgical and obstetrical treatment of
diseases of adults.

Iniorxiou - Conversation with a purpose. Involves both
verbal and nonverbal interactions between people working
toward a common goal.

Inioixiou_sffafogios - Broad conceptual considerations

related to the basic research methodology.

Intorxiou_taotios - Using the appropriate order for the
interview's statements, questions and probes.

Inioryiou_toohniguos - Actions taken by interviewer during
the interview to facilitate communication.

Lafo;adootoi§ - Those who adopt an innovation after most of
their peers.

Loaxningostyio - Stereotyped patterns of learning
characterized by an individual's strengths and weaknesses as

a learner.

Lifo;oyoio - Successive life periods, each of which ushers
in its own variety of learning tasks.

Lifoostruotuio - Basic pattern or design of a person's life
at a given time.

Looaiifo - An outlook which does not extend beyond the
immediate environment.

- ' - Research based on ungrounded
assumptions. Developing a theory first and then setting out
to prove it true or false.

Memos - A way to store ideas about the data and related
information. (note-taking)

- Records of strategies, techniques and
tactics of the research.

5

- Branch of medicine concerned with the functions
of the kidneys.

- When an innovation cannot be plugged
into an established pattern, a whole new activity must be
established.

,Qnooiogy - Branch of medicine concerned with the treatment
of tumors.

Qoinion_ioooors,- Influential menbers in a social system.

- General perspective or area of
study used to begin a grounded research study.

£1oo;ioo_oohoyioi - Geertsma (1982) defines practice

behavior as "any recurring, patterned aspect or segment of
the physician's thinking and actions in practicing
medicine."

Rotoiiai - To send or direct for treatment.

Boiiaoiiity - Probability that an observation can be
repeated either at a different time or at the same time by a
second competent observer and give the same results.

_ - Branch of medicine concerned with the
treatment of diseases of the joints and related structures.

Soooo - Extent of the medical field that a practice
encompasses.

S£l£:dirootod_ioarnor - One who is motivated by internal

incentives, determines personal needs, formulates goals,
identifies resources, chooses appropriate learning
strategies and evaluates the learning outcome.

WW - The degree to which a change

effeCts the physician or patient (e.g. non life-threatening
versus life-threatening).

Singlo.$roof_fronsfoi - When diffusion of an innovation
follows an established path.

Soloooroofioo - A physician in business for himself, no
partners.

- - Physicians who practice a common
subdiscipline of medicine.

Sooiolonoims - Established behavior patterns.

6

- ”A set of inter-related units that are
engaged in joint problem solving to accomplish a common
goal." (Rogers, 1983, p. 24)

- Interactions, both professional
and social, between individuals.

Suosoooiaiist - Physicians concerned with only one aspect of
a specialty

Suhotonfixo_oodos - Those notations that conceptualize the
empirical substance of the findings.

a - Theory developed from one empirical
area and limited to that specific area.

Igoonaoio_momonf - A receptive period when a person has a
need for a skill or knowledge which will solve a life

problem (Havighurst, 1972).

- "One or more distinguishable elements
of technology that are perceived as being closely
interrelated.” (Rogers, 1983, p. 26)

- A record of ideas about codes and their
relationships to each other, categories and developing
theories.

WW - When instances of a category
repeatedly appear and no additional data are being
identified that can develop properties of a categories.

- Those notations that identify how
substantive codes relate to each other

‘ - Process of data collection for
generating grounded theory whereby the analyst collects,
cones and analyzes data and determines what data to collect
next and where to find them.

Ibixfi.psxt¥_2§¥ors - Generally insurance companies that pay

for a patient's treatment.

- "Encountering
information that proves relevant to one' 3 work while not
specifically searching for it, or while engaging in one' s
habitual current- awareness activities, or through the
efforts of a person or agency whose business it is to do
so.“ (Roberts, 1981, p. 158)

.yaiioiiy,- Extent to which the data conform to the facts.

CHAPTER 1
INTRODUCTION

Today's American health care system has become an
immense multi—faceted enterprise. Its scope and depth may
only be equaled by a few human endeavors. Literally
millions of people are involved in health care directly and
indireCtly. They range from those employed by a large
medical support industry to those who operate health care
facilities, health care educators, and those directly
providing health care. According to the 0.8. Department of
Commerce (1984), in 1982 the national health expenditure was
382.4 billion dollars. In that same year, the number of
people inVOlved in direct patient care totaled 5,513,000 in
the 0.5. These figures represent only a small fraction of
the total health care system and biomedical support
industry.

It is within this broad context that individual groups
of health care providers, such as physicians, must be
viewed. Physicians play a critical role in the health care
field as collectively they are involved not only in patient
care but many other facets of medicine, such as national
health care policy formation, medical research, and the
administration of health care delivery systems. While

7

8
certainly not all physicians participate at each of these
levels, there is a general consciousness of the gravity of
the profession and the profound influence it has on our
society.

A great deal of attention and resources are used in the
training of physicians. The basic format of modern medical
education in this country developed around the turn of the
century (King, 1984). The most important conceptual change
occurring then was the establishment of medicine based on
the scientific principles of observation and
experimentation. The Flexner report (Flexner, 1910)
summarized the national trends and served as a catalyst for
changes in medical education (Jarcho, 1975; Chapman, 1974).
Up to this time, education of physicians was provided mostly
by private independent medical schools with very few
opportunities for supervised clinical experiences. In the
United Stated, medical schools, hospitals and universities
developed independently. Developments at the turn of the
century brought about cooperation and, in some cases,
merging of these institutions. This resulted in bringing
academic theories together with the applied practice of
medicine. Following these changes, teaching practices for
medical students have included a strong emphasis on the
basic sciences taught by the didactic lecture coupled with
practical clinical experiences in a supervised setting.

As a result of the emphasis on the scientific method,

seleCtion of medical students has been based primarily on

9
individual predisposition to the scientific process. The
population of physicians is not only a select group
intellectually, but more specifically leans toward a
scientific philosophical bias. Once a member of this
subgroup, continued training based on established
methodology reinforces such tendencies and further
differentiates physicians as a group from the rest of the
population.

Some historical perspective can also shed light on
physicians as a group and how they have been influenced.
Charles Minot (1909), representing what more recently is
considered somewhat of an elitist view (King, 1984)
describes characteristics necessary of a good medical
student, the essential qualities of a physician, and
standards for medical schools.

The man who purposes to study medicine should have
in high degree three gifts, not one of which is common
among mankind, yet all of which he must have...the
power of reliable observation, intellectual endurance,
loyalty.

Examinations should have their main use, not as a
means of admission, but as a means of exclusion, and
the more men of low and middle rank that are excluded
the better...they ought to prove that the candidate has
the preliminary knowledge of chemistry, physics and
general biology without which the pursuit of the
medical science is impossible.

...it is a disgrace to a university to appoint a
man as professor chiefly because he is a ”good
teacher"...only investigators can give university
instruction.

These rather extreme views have never been held by all

people in the medical field; however, this particular

10
mentality has made a significant impression on how medical
students are selected and on perceptions of physicians' role
in society by physicians and other members of society. In
addition, this type of thinking and a host of other
influencing social forces have not only shaped medical
schools but premedical education, graduate medical
education, and continuing medical education as well. It is
with this perspective that physicians must be viewed as
praCtitioners, students and members of a larger social
system, at least to the extent that they exist as a

homogeneous subgroup.

ProhlmArea

Numerous futurist authors, such as Naisbitt (1983),
have outlined the current unprecedented growth in the rate
of change and have projected further advances in the
technical areas such as medicine. Physicians, for example,
are continuously inundated with literature, lectures, and
seminars, all presenting innovations which affect various
aspects of their profession. To keep abreast in their
field, physicians must be aware of what is current, make
critical evaluations of these new developments, and be able
to adapt and change. A physician's decision to make a
change is influenced by a host of factors including the type
of innovation, how it has been presented, by whom, numerous
social and political forces, individual learning habits,

resources available, and the relative advantage over

11
previous practices. In an effort to identify just how
physicians go about making changes in their practices, it
would be useful to integrate and evaluate these and other
variables by investigating three major areas of study:
diffusion of innovations, adult learning, and physicians'
actual practice behavior.

There has been a trend in the last several decades to
identify stages or developmental cognitive steps associated
with various aspects of human life. In addition to the more
life encompaSSing concepts such as Levinson's (1978) life
stages, Erikson's (1980) life-cycle stages, and Havighurst's
(1952) developmental tasks, there are also hierarchical
sequences of development proposed in which adults make
successive transformations while integrating and building on
their experiences (Weathersby, 1980). An example of such a
sequence is Perry's (1970) positions of intellectual and
ethical development. In the same vein, but in the area of
diffusion of innovations, Everett Rogers (1983) has proposed
a series of steps one progresses through while adopting an
innovation. This scheme was synthesized from a composite of
independent studies and observations drawn from various
disciplines and cultures. Although passage through each
step is not mandatory, support is given for a logical
sequential order of those steps taken.

Like other schemes or models of human behavior, it is
uncertain as to what extent such theories can explain,

predict, and ultimately be used to influence behavior.

12
There is the possibility that efforts to construct a change
moael have been influenced by a tendency to categorize and
structure, which may be more influenced by a human desire
for order than a true reflection of the change phenomenon.
Conversely, if a change model could be developed and
substantiated, it would serve as a useful tool to facilitate
and understand change better.

The key to identifying a change process is in observing
and describing physicians' behavior. The investigation must
extend beyond identifying journals read, continuing
education courses taken, and with whom physicians socialize.
An important consideration which must be examined in
addition to these factors is why does the physician change.
It is essential to examine the various psychological forces
which impact physicians. Simply identifying the mechanics
rather than the impetus or motivation is not likely to be

entirely productive.

RHLDQSH

The purpose of this study is to describe physicians'
behavior as they make changes in their practice. This
approach is an effort to integrate both how and why
physicians make changes. It is necessary to investigate not
only learning activities associated with change such as
journals read, lectures attended, and colleagues consulted,
but also to correlate these activities with why and how such

activities are pursued. Hence, characteristics of

13

physicians as lifelong learners are viewed with respect to
social, psychological, economic and professional influences.

One focus of this description of physicians as
individuals involved in learning and making changes is to
identify common experiences. From these common experiences,
shared learning patterns and change mechanisms can be
identified. To do this, the following questions represent
general areas of investigation:

1. What are the types of changes made by physicians?

2. Why do physicians seek change?

3. Under what conditions was the change sought and
implemented?

. What learning activities are associated with

changes?

Why were particular learning activities pursued?

Are there common reasons for change?

Are there common learning activities associated

with change?

. Are there common methods or processes of change?

(b “0‘01 15
too

These questions do not define the parameters of this
study, but do serve as orienting concepts about which to
focus.

The medical world is currently undergoing tremendous
change, not just in terms of medical advancements but also
in its social structure. Physicians' relationships with
health care institutions, professional organizations,
government, other health care providers, patients, third
party payers, industry, and colleagues are all being
reevaluated and redefined. For the most part, physicians
have little choice but to adapt in response to their ever
changing environment. Simple survival in a medical practice

requires an ability to change if in nothing more than the

14
medical aspects of a practice. Making changes requires some
kind of internal restructuring whether it involves acquiring
new information, redefining concepts or establishing new
priorities. Regardless if changes result in cognitive or
affecrive alterations, most change requires learning. The
value of this study is in examining the physician as a

learner in the change process.

Methodolssx

The research methodology used in this study is called
grounded research. As described by Glaser and Strauss
(1967), this methOdology provides a means of
phenomenologically developing concepts, hypotheses, and
theories which are systematically obtained and analyzed from
data. Initially, an orienting focus or perspective serves
as a point from which to begin. Observations relating to
this focus are obtained and used both to guide the ongoing
research and inductively develop theory.

The emphasis in grounded research is that the
generation of theory involves a process of research. This
process begins not with preconceived notions but by building
concepts and ultimately theory from data. As the process
continues, the data itself shapes and molds the direction of
the research. Grounded research differs from the more
traditional logico-deductive method in which a theory is
postulated from 'a priori assumptions." These preconceived

notions may or may not have.been developed from related

15
data.

Data collected in a traditional logico-deductive method
is focused primarily on verification of a theory. Grounded
research, on the other hand, provides a mechanism for
generating theory. Generating theory by grounded research
methods involves a process of research which is fluid and
originates from the data itself. Glaser and Straus (1967)
view grounded research as ”an ever-developing entity, not as
a perfected product." (p. 32)

Grounded research is useful when investigating areas in
which little is known and where quantitative methodologies
are not useful because of an inability to identify or
central variables. Other advantages inherent in grounded
research, according to Glaser and Strauss (1967, p. 3)
include:

...generating grounded theory is a way of arriving at
theory suited to its purposed use.

...laymen involved in the area to which the theory
applies will usually be able to understand it.

Theory based on data can usually not be completely
refuted by more data or replaced by another theory.

Grounded theory can help to forestall the opportunistic
use of theories that have dubious fit and working
capacity.

...help interpret or explain the data in a general
manner.

In addition, grounded research provides a mechanism for
effeCtively identifying social interactions and their
structural context in society.

Grounded research was chosen as the research

16

methadology for this study because of the lack of research
and knowledge in this area and because describing how
physicians go about making changes in their practices does
not lend itself to quantitative research methods. Although
some research has been done examining aspects of this study,
such as physician networking and resources used by
physicians, little work has been done centered on the
physicians' learning process as the subject of the research.
Those studies most similar to the approach taken here are
based on logico-deductive theory techniques. Consequently,
the physician as a learner, practitioner, and innovator has
not been viewed from a grounded research perspective.

The interview technique for data collection was adopted
for this study because it could be relatively unstructured,
allowing data to emerge from the subjects without greatly

limiting participants' responses.

Assumptions

Several assumptions were made at the onset of this
study concerning both the research methodology and the study
participants. First of all, the grounded research
methOdology, discussed in Chapter III, has not been a common
research technique used in the study of physicians or the
general health care field. There has not been an extensive
history in this particular area demonstrating the usefulness

of grounded research. It is assumed that because of its

application in various other fields, grounded research can

17
also be useful in this area. It is also assumed that a
semi-structured interview technique of data collection can
yield meaningful and useful data.

The second major assumption concerns physicians'
ability and willingness to identify changes in their
practices and accurately describe them. It is also assumed
that these changes or at least many of them are a result of
the physicians' own free will and not simply imposed by some
external influence.

It is assumed that changes made in any aspect of a
medical practice require learning by the physician. That
is, changes are not capriciously implemented but require
some kind of information seeking, means of evaluation and/or

knowledge for implementation.

1' 'I |'

One of the major areas which defines the limits of this
study is the research population. Participants include
physicians from internal medicine and obstetrics/gynecology
specialties who, upon invitation, volunteered to participate
in the study. All participating physicians work in private
practice, either in solo or a group practice, and are also
volunteer clinical faculty for a state operated medical
school. These physicians take part in the learning
experiences of medical students and residents by presenting
leCtures, meeting regularly to discuss specific patient

cases, and including medical students and residents in the

18
care of their patients.

Physicians participating in this volunteer teaching
program were chosen for two reasons. First of all, because
of the highly demanding daily work schedule most physicians
have, obtaining cooperation for this study is more likely
from physicians who have at least some interest in the
educational process. Thus the selection of this group of
physicians excluded others, such as physicians working in
health maintenance organizations, public health physicians,
and physicians working in industry.

A second reason for selecting this population of
physicians involves the geographic proximity to the
researcher. This limits the study group to private practice
physicians working in a medium size metropolitan city.
Because there is no university research facility in the
immediate area, this study excludes physicians practicing
academic medicine. Additionally, the geographic limitations
eliminated physicians who practice in rural areas.

The size and nature of the research group also
establisnes limitations in this study. Broad
generalizations extending beyond the areas studied are
limited because the research group is small and restricted
to a defined population of physicians. In a descriptive
study such as this, the question of external validity is not
a significant concern as there is no attempt to achieve
representativeness of the experimental findings. Comparing

and contrasting the two study subgroups, which is consistent

19
with grounded research methods, will help to confirm
findings about each subgroup and establish a degree of
evidence for more general conclusions between the two
populations.

Another limitation of this study is the subjects'
willingness and ability to give an accurate description of
learning experiences associated with changes made in their
practices. This may be a result of a physician's desire to
meet his or her own ego needs or a sense of responsibility
to some other consideration such as a group practice. The
ability to accurately recall events over a span of several
years also makes it difficult for physicians to give an
accounting of their behavior.

The very nature of the research methodology employed in
this study sets limitations on the study. Data collected is
not only a function of the subjects but also of the
researcher's ability to elicit responses, record data
accurately, make astute observations, and to direct the
study. The general area of reliability is an inherent
uncontrolled factor of grounded research. The data are
subjected to the interviewer's perspectives, bias, and
powers of observation. One effort to reduce these variables
is that all the interviews were done by one researcher.
Also, when possible interviews were tape recorded and

transcribed, providing an accurate account of what was said.

20
5' 'E' E II S! l

The value of this research project is in examining
physicians' roles as learners in the change process. The
focus is on physicians' behavior and how that behavior
relates to the many variables concerning the practice of
medicine. This study occurs at the intersection of various
disciplines and has the potential of contributing to broad
areas of study such as lifelong learning and the change
process.

A close examination of physician learning patterns may
be useful in better understanding adult learning,
particularly in the professions. There has been
considerable thought and research in an effort to identify
who adult learners are, why they learn, and how they go
about learning. What remains to be seen is whether or not
the subgroup of physicians conforms to patterns identified
in the general population and other subgroups. If there are
differences or at least subgroup specific characteristics,
are they a function of the individuals attracted to that
particular area or an intrinsic element of the profession
itself? Can all adults be viewed as one group of learners
or are the differences between subgroups too great? Are
there significant differences in learning patterns within
the subgroup of physicians or even within a specialty group?
Is there a developmental pattern to adult learning

associated with making changes and can it be generally

applied to all adults or are there significant differences

21
between subgroups within the population?

Identifying how physicians learn may be useful in
promoting more effective and efficient learning; however,
what might be more useful is identifying why they learn.
Physicians have, by virtue of having attended medical school
and residency programs, demonstrated an ability to learn in
a variety of learning modes and situations. Physicians may
need little, if any, help in acquiring information once they
are motivated to do so. Therefore, understanding what
stimulates physicians to learn may prove to be an effective
tool in promoting and facilitating learning.

The study of learning associated with changes is but
one element in a broader field, the communication of
innovations. This area of study examines aspects of change
such as how an innovation is generated, how it diffuses in a
social system, characteristics of the diffusing innovation,
communication channels used, and the time it takes for an
innovation to diffuse throughout a social system.
Additionally, a major area of interest is the
innovation-decision process. How does an individual or
organization go from first knowledge of an innovation,
through the investigation and decision to adopt or reject
process, and ultimately to a final confirmation of that
decision? Studying physicians' learning behavior can
contribute to this body of knowledge by identifying learning
aetivities associated with these various aspects related to

the communication of innovations. Physicians are a good

22
group to study change related behavior because medicine is
in a constant state of change.

For physicians, change is an integral component of
their medical practice. If a pattern of change exists, it
is most likely to be identified in this actively changing
group.

There is a need to know more about how physicians make
changes in their practices and what role learning takes in
this process. Adequate, cost effective, appropriate and
up-to-date health care depends on keeping health care
providers knowledgeable, willing and able to make changes.
Among those interested in improving and promoting health
care changes are physicians' professional organizations,
third party insurance companies, industry, government,
hospitals, biomedical researchers, health maintenance
organizations, consumers, and continuing medical educators.
For the most part, these individuals or organizations have a
vested interest in improving the health care delivery system
and would benefit by better understanding physicians as
learners.

This study is also of significance because it can
contribute to the understanding of physicians' learning
behavior based on a grounded research methodology. The
approach provides a systematic means by which data is
collected and from which conclusions and hypotheses are
derived. A descriptive approach such as this one has not

been typically used in the study of physicians' learning

23
behavior. Results from this qualitative inquiry can help
establish the usefulness of grounded research in the field

of medical education.

WWW

In Chapter I, the writer has established a basic
orienting concept about which this study centers. A review
of the related research establishing background information
is provided in Chapter II. An outline of the research
methoaology and specific implementation of the study is
presented in Chapter III. In Chapter IV, the writer
presents the findings and discussion of the study. The
conclusions and implications of the study are outlined in

Chapter V.

CHAPTER II

REVIEW OF THE LITERATURE

A broad base of understanding must be developed in
order to identify and understand the learning activities
physicians experience as they incorporate changes into their
practice. This base includes knowledge of who the
physicians are as learners, why they learn and what
influences their learning.

To answer these questions, this chapter discusses the
literature concerning adult learning, the communication
process, cognitive stages in the innovation-decision process
and learning as it occurs in the medical field.
Characteristics of the two physician groups studied and
various social factors affecting them are discussed in

subsequent chapters.

Wm

One primary concept which this study centers on is
adult learning. Adults possess unique learning
characteristics and are also shaped by many adult-specific
facrors. It is within the context of these special
qualities of the adult learner that this study must be
viewed.

24

25
WW

Unlike younger individuals, adults approach learning
with a rich and extenSive past history. Kidd (1973, p. 45)
characterizes adults as having more experiences, different
types of experiences and experiences that are organized
differently than other learners. When these adult-specific
life experiences interphase with learning experiences,
adults are most likely to pursue learning endeavors.
Havighurst (1952, p. 4) describes this juncture of life
experiences and learning experiences as a "teachable
moment." That is, when a person experiences a need for a
skill or knowledge which will solve a life problem, their
motivation to learn is heightened.

Furthermore, Kidd (1973, p. 37) sees adults solving
problems with no "correct" answers. Answers to many adult
problems cannot be verified to the point of no doubt. This
is the uncertainty that adults must learn to live with.
Also, adults are bound by roles and traditions that force
stereotyped answers on the adults which may not be entirely
rational. Lastly, when adults make decisions, they are
likely to have immediate effects upon others.

Knowles (1980, p. 18) describes adults as self-directed
learners who are motivated by internal incentives. As a
result, the adult learner takes the initiative, determines
personal needs, formulates goals, identifies resources,
chooses apprOpriate learning strategies and evaluates the

learning outcome. So different is adult learning that

26
Knowles (1980, p. 19) uses the term 'andragogy“ to refer to
the ”art and science of helping maturing adults to learn.“
Supporting this self-directedness, Tough (1971, p. 16) has
studied the adult learner and found that adults engage in
about five learning activities per year (one learning
aCtivity involving 100 hours) and that 70 percent of these
are self-planned. Adult learners are not only
self—motivated but pursue learning primarily in informal and
independent ways.

The need to progress through a series of sequential
steps characterizing human development can be viewed as one
source of motivation for inner—directed learning. For
example, Erikson (1980, p. 129), has outlined eight stages
in a life cycle in which certain developmental tasks must be
accomplished and critical issues resolved to progress to the
next stage. Levinson (1978, p. 18) describes age-linked
periods related to patterns or designs of a person's life at
a given time. Learning activities occur when it is
necessary to change behavior in order to maintain an
equilibrium--goodness of fit--between one's life structure
and one's experiences of self. Motivation for adult
learning can also be seen as a need to progress through
Maslow's (1970, p. 35) human needs hierarchy--physiological,
safety, belongingness and love, self-esteem, and
self-actualization--where fulfillment of one set of needs is
generally achieved before embarking on the next higher

level. While it may not be clear if progressive development

27
through these various schemes is a universal, innate human
desire or a dictum of society, it is reasonable to assume

that these factors do influence the way adults learn.

W

Tough (1982) has also studied adults as they make
intentional changes. Intentional changes are those that
occur when a ”person clearly chooses the particular change
and then takes one or more steps to achieve it." (p. 20)
Four major areas of intentional change, accounting for about
75 percent of all intentional changes, were identified:
occupational, changes in human relations, recreational, and
changes in the location of residence. (p. 25) The number of
intentional changes varies greatly with the level of
education and social class. Approximately one-third of all
intentional changes are related to one's occupation or
profession.

Unintentional knowledge acquisition and change,
although not part of Tough's study, does play a significant
role in adults' lives. Menzel (Roberts, 1981, p. 158)
defines unplanned acquisition of information as
"encountering information that proves relevant to one's work
while not specifically searching for it, or while engaging
in one's habitual current-awareness activities, or through
the efforts of a person or agency whose business it is to do
so.”

Menzel also identified three types of unplanned

28
acquisitions of information in the biomedical field which
include searching for one thing, coming across another;
being sought out by a colleague to transmit information; and
being told by a colleague while together for another
purpose. There are some advantages to unplanned acquisition
of information. For instance, interpersonal networks often
result in information coming unsolicited from individuals in
other disciplines.

Learning as a result of informal contacts and unplanned
events can be viewed in relation to formal acquisition of
knowledge. Both are essential for good communication and
making changes. Menzel (Roberts, 1981) voices a belief that
formal and informal knowledge acquisitions are not only
mutually supportive but can also be used to enhance one
another.

Will the advances in information engineering ever
make informal scientific communication obsolete, or
does informal communication play an indispensible role?
I believe the answer to that question is that
interpersonal and unplanned communications must
continue to play their crucial role in science and

technology but that formal steps can be taken to
maximize fruitful encounters. (p. 155)

E3 II E . Bi I'
Houle (1963, p. 7) has summarized characteristics of
adults who pursue continuing adult education and found that
by far the most influential relationship was ”the higher the
formal education of the adult, the more likely is that he

will take part in continuing education." Members of high

29
income groups and those in the late 203 to 50 age group are
more inclined to seek continuing adult education. The
larger the community, the greater length of residence in it,
and the number of different kinds of programs available are
other factors in adult continuing education. Additionally,
married people participate more than singles; professional,
managerial and technical people more so than other
occupational groups; and finally, white-collar and clerical
workers, then skilled laborers and lastly unskilled
laborers.

Houle's (1963, p. 15) own research concerning adults'
continuing education revealed that all learners studied ”had
goals which they wished to achieve, they all found the
process of learning enjoyable or significant, and they all
felt that learning was worthwhile for its own sake." What
did differ among these adults was the major conception about
the purposes and values of continuing education. Houle
defined three subgroups which included those who were
goal-oriented, those who use education to accomplish fairly
clear-cut objectives; activity-oriented, those who
participate just for the intrinSic value of the activity
itself; and learning-oriented, those who pursue knowledge
for its own sake. Houle qualifies his findings by saying
"These are not pure types; the best way to represent them
pictorally would be by three circles which overlap at their
edges. But the central emphasis of each subgroup is clearly

discernible."

30

Houle (1980) has also identified three modes of
learning for the adult professional. The first is the mode
of inquiring, which involves creating some new idea,
technique or policy. Exploration and discovery are typical
activities of this mode. Secondly, the instruction mode is
primarily involved with the process of disseminating
established skills or knowledge. This is the most familiar
because of its common use in classroom instruction. The
performance mode involves learning by doing. This is the
type of learning mode students in "practical or clinical"
experiences engage in. Houle has demonstrated how the
invention of new processes can incorporate all three

learning modes.

The decision makers of the profession (sometimes
stimulated or assisted by outside opinion) must use the
mode of inquiry, sometimes in an elaborate and complex
fashion, to identify the essential nature of the new
method or theory and explore the ramifications of its
application, thus educating themselves to both aspects.
When a basic procedure has been established, it is
disseminated by the mode of insiiuotion to the other
practitioners as well as to concerned external publics.
The changed behaviors that should result are then
encouraged by the mode of ooifoimanoo so that they
become established in practice and are monitored by
whatever means seem appropriate in the various
workplaces in which professionals are employed. During
this whole process, the advocates of alternative
methods (including the traditional way of work) will
usually actively advance their own views, but they too
will shape and spread their views by using the same
three modes." (p. 33)

W11
Another way of looking at the adult learner is to

examine Kolb's (1974, p. 23) learning model. This model

31
combines learning and problem solving and is both active and
passive, concrete and abstract. The four-stage cycle can be
conceived as: 1) concrete experiences followed by
2) observation and reflection leading to 3) formation of
abstract concepts and generalizations which lead to
4) hypothesis which is tested in future actions, leading to

new experiences.

Concrete
experiences

Testing implications Observation and
of concepts in reflections
new situations

Formation of abstract
concepts and generalizations
Fig. 1

Several observations are drawn from this model.
Concepts in experience are continuously tested and modified
as a result of observation of the experience. Kolb (1974,
p. 28) states that ”In a very important sense, all learning
is relearning and all education is reeducation." Secondly,
one's felt needs and goals determine to a large degree what
learning tasks and experiences are undertaken, and how they
are interpreted. Consequently, clear goals and objectives
are essential. Thirdly, individual needs and goals

influence the learning process in that individual learning

32
styles develop which emphasize one or more of the components
of the model. Kolb (1974b) states that:

As a result of our hereditary equipment, or
particular past life experience, and the demands of our
present environment, most people develop learning
styles that emphasize some learning abilities over .
others. We come to resolve the conflicts between being
active and reflective and between being immediate and
analytical in characteristic ways. (p. 29)

As a result of Kolb's self-descriptive Learning Style
Inventory, which measures an individual's strengths and
weaknesses as a learner, some dominant types of learning
styles have emerged.

Conyorgoi--dominant learning abilities are abstract
conceptualization and active experimentation. This
individual's greatest strength lies in the practical
application of ideas and tends to specialize in the
physical sciences like engineering.

‘Diuoigor--best at concrete experience and reflective
observation. This individual's greatest strength lies
in imaginative abilities. They tend to view concrete
situations from many perspectives and are often found
in the humanities and liberal arts.

Assimiiafor-- dominant abilities are abstract
conceptualization and reflective observation. These
individuals have an ability to create theoretical
models and tend to be in the basic sciences rather than
the applied sciences.

.AooommodatoL--is best at concrete experience and active
experimentation. Their strengths lie in doing things,
carrying out plans and experiments, and in new
experiences. These individuals are often in technical
or practical fields such as business.

Evidence indicates that one's chosen field of work to
an extent helps shape a learning style but it is more likely
that a learning style predisposition guides an individual
into a particular field. However, this finding was not

supported by work done specifically with physicians.

33
Wunderlich (1978), for instance, found no predominant
learning style type associated with physicians. Whitney
(1978), also studying physicians, supports this lack of
career choice-learning style correlation but did find that
learning styles relate to the type of continuing education
programs preferred by physicians. Data from this study
indicates that family physicians attending a refresher
course were more likely to be convergers. Differences were
also found when studying instructional methods preferred by

physicians.

WWW

Aside from the decline of physiological abilities
accompanying aging such as loss of visual acuity, hearing
loss, and a slowing of reflexes, adults also change in terms
of mental ability with aging. Cattell (1963) and Horn and
Cattell (1966) claim that intelligence should be viewed as
being composed of two components, each varying differently
with increasing age. These two types of intelligence are
called fluid and crystalized intelligence.

Fluid intelligence is associated with "perceiving
relations, educing correlates, and maintaining span of
immediate awareness in concept formation and attainment,
reasoning and abstracting.” (Horn, 1968) This type of
intelligence has a neurophysiological basis and is
influenced by biological variables such as heredity, cucal

cortic-- cell count and brain cell injury. Fluid

34

intelligence reaches its peak before biological maturity
(15-20 years of age) and gradually declines from that pOint.

Crystalized intelligence is associated with
"performance in which skilled judgment habits have become
crystalized (whence its name) as the result of earlier
application of some prior, more fundamental general ability
to these fields." (Cattell, 1963) Crystalized intelligence
seems to increase from the onset of adulthood. The two
types of intelligence are practically indistinguishable in
early development; however, a gap develops upon biological
maturation and continues to widen with aging. An adult's
intelligence seems to remain fairly constant throughout the
aging process but the nature of the intelligence does

change.

I] C . I' E
The communication process is a second fundamental
process underlying this study. Everett Rogers (1983, p. 5)

defines communication as "a process in which participants
create and share information with one another in order to
reach a mutual understanding." It is the diffusion process,
a specific type of communication, which is of most interest
in this study. Diffusion is "the process by which an
innovation is communicated through certain channels over
time among the members of a social system." (Rogers, 1983,
p. 5) This is essentially the same as Berlos' (1960, p. 30)

S-M-C-R communication model where a source (S) sends a

35
message (M) via certain channels (C) to the receiving
individual (R).

Most studies of how people make changes in their lives
focus on the adoption of an innovation. Change in response
to an innovation certainly does not account for all changes
made in one's life; however, in a rapidly changing technical
field such as medicine, it does play a major role. In
Rogers' (1983) text, Diffusion_of_1nnoyations, this
diffusion process is conceptualized as having four elements:
the innovation, communication channels, time, and the social
system. This provides a basis for a general understanding

of the diffusion process.

Won

Rogers (1983) defines an innovation as "an idea,
practice, or object that is perceived as new by an
individual or other unit of adoption." (p. 11) It is
carefully pointed out that the "newness" aspect of an
innovation is not strictly limited to new knowledge but also
extends to forming a favorable or unfavorable attitude
toward it or adopting or rejecting it. Often an innovation
will have both a hardware aspect, such as a new tool, and a
software aspect, consisting of the information base for
using the tool. Innovations vary greatly in the dominance
of either aspect. Information sought about an innovation is
usually either software knowledge, which answers the what,

how and why questions, or innovation-evaluation knowledge,

36
which pertains to the advantages and disadvantages of
adoption.

Not all innovations diffuse at the same rate. Among
the many influencing factors, Rogers (1983, p. 210) has
cited five characteristics of innovations which are of
greatest significance in explaining differing rates of
adoption.

-the degree to which an innovation is
perceived as better than the idea it supersedes.

Compatibility-the degree to which an innovation is
perceived as being conSistent with the existing values,
past experiences, and needs of potential adopters.

Complexity-the degree to which an innovation is
perceived as difficult to understand and use.

Ilialabiliix-the degree to which an innovation may be
experimented with on a limited basis.

QbfislxahiliLx-the degree to which the results of an
innovation are visible to others.

Another important aspect of innovations is that they
are often closely related and adopted as a package. Rogers
(1983) refers to this as a I'technology cluster,“ which he
defines as I'one or more distinguishable elements of
technology that are perceived as being closely
interrelated.” (p. 226) In addition to adopting several
innovations simultaneously as a group, the adoption of one
may trigger the adoption of several other closely related
innovations.

Solo and Rogers (1972, p. 11) have outlined three
different ways an innovation can diffuse through a social

system, all of which influence the rate of diffusion.

37
First, a singio Lino; transfer occurs when the diffusion of
an innovation follows an established path, as innovations in
a technology cluster might diffuse. Non Lino; transfer
occurs when an innovation cannot be plugged into an
established pattern; a whole new activity must be
established. Lastly. £1955 tract transfer refers to the
transfer of an innovation to a completely different

unrelated purpose.

WW

Communication channels play an integral component of
the diffusion process as they are being used to transmit
messages from the source of information to the receiver.
Communication channels can be viewed as either coming from a
localite or cosmopolite source and/or as interpersonal or
mass media in nature. (Rogers, 1983, p. 198) Evidence
suggests that communication channels function differently at
various stages in the diffusion process. (COpp, 1957; Beal
and Rogers, 1960, p. 6) For example, mass media is more
influential at the initial dissemination of information
stage, whereas interpersonal communication within peer
groups is more important when forming an opinion or making
the deciSion to adopt an innovation. Also channels used by
early adopters differ from those used by later adopters.
(Beal and Rogers, 1960, p. 19) Often early adopters rely on
mass media channels to make adoption decisions, whereas

later adopters are more likely to use interpersonal

38
channels.

Interpersonal communication can be viewed as either
being between individuals who are alike or "homophilous" or
dissimilar, which is termed "heterophilous.“ (Rogers, 1983,
p. 18) It has been demonstrated that the most effective
communication occurs when individuals are homophilous. In
faCt, a major problem in communication of innovations is
that individuals are too dissimilar, heterophilous. There
is too large a gap between those who are change agents and
the target population. A more desirable situation is when
the individuals involved are just slightly different from

one another.

Tim:

The innovation-decision process (discussed later) is
viewed as a series of information-seeking and
information-processing steps an individual or group goes
through when adopting an innovation. The time it takes for
this process, the innovation-decision period, is influenced
by a variety of factors including the aforementioned five
characteristics of innovations. Time related attributes can
also be related to the adopters, at least when examining
individual-optional innovation decisions.

The innovativeness of an adopter refers to how early an
innovation is adopted compared to other members of a social
system. Rogers (1983) has identified five categories of

adopter innovativeness. The five categories, which range

39
from high to low, are innovators, early adopters, early
majority, late majority, and laggards. Members of each
category typically behave in a particular pattern. For
instance:

Innovators are active information seekers about
new ideas. They have a high degree of mass media
exposure and their interpersonal networks extend over a
wide area, usually reaching outSide of their local
system. Innovators are able to cope with higher levels
of uncertainty about an innovation than are other
adopter categories. As the first to adopt a new idea
in their system, they cannot depend upon the subjective
evaluations of the innovation from other members of
their system. (p. 22)

Typically, if the number of individuals adopting an
innovation is plotted on a cumulative frequency basis over
time, an S-shaped curve results. At first, only a small
number of individuals, the innovators, adopt, followed by
the early adopters, early majority, and so on. The curve or
rate of adoption varies in its slope from one innovation to
another. Even the same innovation in different social
systems will diffuse at different rates, which indicates
that social systems play an important role as do the

characteristics of the innovation.

MW

Rogers (1983) defines a social system as "a set of
inter-related units that are engaged in joint problem
solving to accomplish a common goal." (p. 24) Generally,
social systems consist of patterned communication structures
which are both formal (bureaucratic organizations) and

informal (interpersonal networks) in nature. The informal

40
structure, aside from the heterophily/homophily concept
discussed earlier, consists of influences such as system
norms (established behavior patterns), opinion leaders
(influential members in the social system, usually at the
center of interpersonal communication networks), and change
agents (one whose purpose is to influence others' decisions
to change). Because each social system has its own
particular variables such as these, diffusion of even the
same innovation will vary greatly between different social

systems.

I] I I' -E . . E

The innovation-decision process, which is just one
component of diffusion, is of most interest in this study.
This process is viewed as a phenomenon which occurs over
time and is characterized by a series of sequential learning
steps individuals or organizations engage in, when

incorporating a change.

5 | E El . I] I . _[ . . E ggfifi
The notion of subdividing behavior into stages has a

long history in social psychology. John Dewey (1933,

p. 106) describes a five stage process by which

problem-solving activity occurs. Much of the evidence

supporting the existence of stages in the

innovation-decision process comes from agricultural

diffusion of innovation studies. (Ryan, 1943; Beal, 1957;

41
Copp, 1957; Beal and Rogers, 1960).

Wilkening (1953) was one of the first to demonstrate
that an individual's decision to adopt an innovation takes
place in stages. He describes the adoption of an innovation
as:

...a process composed of learning, deciding, and

acting over a period of time. The adoption of a

specific practice is not the result of a single

decision to act but of a series of actions and thought

processes." (p. 9)

Wilkening cited four adoption stages: awareness, obtaining
information, conviction and trial, and adoption.

Several studies of nonfarmers (LaMarr, 1966; Kohl,
1966) involving school personnel also support the notion of
stages in the innovation-decision process. Additionally,
Coleman's (1966) study of physicians' drug adoption
practices supports the validity of stages. While these
studies all generally support the concept of stages, there

is some disagreement regarding the number of stages and

exactly how the process is to be subdivided. (Mason, 1966)

E , I l' -E . . E H i J

The process of change in response to an innovation has
been studied extensively in various disciplines, most
notably in agriculture and business. (Rogers and Shoemaker,
1971) While several schemes have been designed depicting
this process, the five stage model proposed by Rogers (1983,
p. 163) provides the most comprehensive framework and

integrates various concepts into the scheme: prior

42
conditions, communication channels, characteristics of the
decision-making unit, and perceived characteristics of the
innovation (see Appendix A). This model was derived from a
synthesis of various interdisciplinary works, all
contributing to a component of the scheme. The five stages
of Rogers' innovation-decision process are knowledge,
persuasion, decision, implementation, and confirmation.

The knoulodgo stage begins when an individual is
exposed to the innovation's existence and acquires some
understanding of how it functions. This stage requires the
individual to have a motivation or need. Here a question of
passive versus active acquisition of knowledge arises: does
the need for an innovation stimulate knowledge acquisition
or does the innovation itself create the need? In either
instance the individual is stimulated to see how the
innovation works, how to use it, and what the principles are
underlying the innovation's functioning.

During the potauasion atago, a favorable or unfavorable
attitude is formed about the innovation. Unlike the more
cognitive knowledge stage, this second stage involves
thinking that is more affective in nature. At this stage,
information is more actively sought but in a selective
nature, thus establishing general perceptions of the
innovation's relative advantage, compatibility, and
complexity.

At the dooiaion ataga, an individual chooses to either

adopt or reject the innovation. Often a small scale trial

43
is part of this stage. Sometimes the trial may be done by a
”near peer,“ thus substituting for an individual's own trial
of an innovation.

The imoiomontation stago occurs when the innovation is
actually put into use and required an overt behavior change.
Informational needs at this stage revolve around operational
problems such as ”how is the innovation used?" This stage
ends once the innovation is institutionalized; that is, it
loses its character as a new idea.

The last component of this innovation-decision model is
the oonfitmation ataoo, in which support for the
adoption/rejection decision is sought. This stage can
continue for an indefinite period of time and can also lead
to a reversal of the original innovation decision if new
evidence is encountered.

While Rogers (1983) does argue for the existence of
stages in the innovation-decision process, he does state

that:

The evidence is most clear—cut for the knowledge
and decision stages and somewhat less so for the
persuasion stage. There are rather poor data on
distinctiveness of the implementation and confirmation
stages. (p. 193)

T] E E E' i' J I l'

The process of changes in the medical field involves
many highly interrelated components. Several authors (Luhr,
1981; Moskowitz, 1981) have attempted to build conceptual

models which integrate various components of the biomedical

44
innovation process. Furthermore, numerous approaches have
been taken to investigate the diffusion of medical
innovations among physicians. Such efforts include
investigating how effectively an innovation has diffused
(Stross, 1979), correlating sociometric relationships with
diffusion of innovations (Coleman, 1966; Winick, 1961;
Menzel, 1955; Wenrich, 1971), developing a change model
(Geertsma, 1982), identifying sources of information and
communication channels used at various stages in the
innovation-decision process (Manning, 1978, 1980), and
examining information acquisition and utilization
(Bernstein, 1981). Issues centered on continuing medical
education have also generated an interest in investigating

physicians and the change process.

5' i' J I I' H i 1

Two major goals in the biomedical field are to diffuse
technologies into medical practices and to remove outmoded
technologies. _Because this requires coordination involving
many participants, a conceptual framework has been sought
through which various otherwise unrelated individuals and
institutions can work in a coordinated way.

Lohr (1981) describes a two step medical technology
assessment "loop." The first step is the generation and
analysis of research data. The model conceptualizes an
“upward" transmission of data and related analysis from the

researcher, who may also be a practitioner, to a level

45
responsible for further analysis and synthesis. Following
this assessment, the second route, interpretation and
dissemination, leads "downward” to the practicing physician.
Lohr proposes that the medical community plays a pivotal
role in this scheme at the assessment level. Physician peer
review institutions such as Professional Standards Review
Organizations (PSROs) could be charged with this
responsibility.

An ”upward" flow of information from the field
includes identifying research problems and gathering
data for analysis and interpretation, and we have
hypothesized that (at least some) PSROs can carry out
these tasks in ways that complement or supplement
existing data collection activities. To date, little
thought has been given to this kind of function for
PSROs, so there is a paucity of theoretical or
conceptual literature on the topic as it might pertain
to PSROs. (p. 11)

Moskowitz (1981, p. 3) has proposed a hypothetical
model describing the process of biomedical innovation with a
particular orientation toward biomedical research. This
moael was derived primarily from fields outside the

biomedical area.

 

 

   

 

N '
idea idea idea
Generation . . .
Communication UtilizIanon and amnion
D”. opmen Into Practice
' . Demonatration
63:33:“ Applied Research and Education Health
n"..'¢h .Nd mv.|opm.n‘ ”0".m‘ P'.cflc.
Knowledge
Knowledge
Knowledge Validation Transfer

Acquisition

Evaluation i/

Fig. 2

46

The top arrow of this biomedical research spectrum
indicates an overall flow of innovation. Four distinct
stages are identified. The first stage is the generation of
ideas in basic, clinical, and applied research. Motivation
for these ideas lies in the desire to understand life
processes and the disease process more fully. The second
stage is the communication of ideas. This refers to the
transfer of information among researchers. The third stage
describes the development of clinical applications. Here,
societal needs dictate the practical applications of the
research and focus on the diagnosis and treatment of
disease. The middle arrow of this model specifies the
categories of research currently funded to advance
biomedical research. The third arrow outlines the primary
objectives of each phase of the research continuum.

The final component of this model is evaluation and
links the four stages. Because an evaluation process is
built into a research design, it is an integral element of
each stage. This evaluation process is accomplished not
only by the nature of the scientific method but also by the
peer review system in the biomedical research community. In
addition, before a technology is released for general use,
formalized evaluation and validation are done in the form of
clinical trials or other validation research. This is
usually done at the third stage.

Using this model as a conceptual framework, Moskowitz

views the health care industry as being significantly

47
different from other industries.

In at least one subset of biomedical researchers
there is a close relationship between the idea
generators (biobehavioral and biomedical researchers)
and those who put the technology into practice,
physicians. In industries related to consumer goods,
such as the automobile and electronics industries,
researchers come from disparate basic disciplines such
as chemistry and metallurgy. These researchers
certainly use the ultimate products of their research
but cannot be considered to promote or prescribe them
in the marketplace. In the health sector, however,
practitioners often enjoy the opportunity of a close
relationship with researchers." (p. 4)

Wm

Coleman's (1966) study is one of the earliest
addressing diffusion of a medical innovation and, like many
studies done in this era, examines the diffusion of a new
drug. While Coleman did not actually develop a change model
based on this work, it remains an important component of
Rogers' innovation-decision process and also contributes
greatly to the understanding of how physicians adopt
innovations.

The primary focus of Coleman's (1966) study was to
examine those characteristics of physicians that were
related to the time of adoption of the specific drug under
study. In so doing, the following topics were examined:

1) The doctor's medical and nonmedical background.

2) His orientations and attitudes toward various

aspects of medicine and toward his community.

3) His exposure to various formal and informal

sources of information about new drugs.

4) His own account of the influences affecting his

decision to adopt gammanym (if he adopted it).

5) His general use of the family of drugs which
gammanym is a member and his treatment of

48
specific conditions requiring their use.

6) His relations with other doctors within the local
medical community; his friends, his informal
consultants, his 'advisors.” (p. 20)

What is most outstanding about this extensive work is that
physicians' behavior was described by written records
obtained from pharmacists' prescription files. This rather
tangible dependent variable made it possible to accurately
follow the diffusion pattern over an extended period of
time.

The population under study consisted of 216 physicians
practicing in four Midwestern communities. Physicians were
chosen from three specialty groups: general practitioners,
internists, and pediatricians. Data obtained from these
subjects through personal interviews and prescription files
revealed information concerning the diffusion of the new
drug, characteristics of the innovators, factors influencing
physicians' decisions to adopt, and the influence of social
and professional networks on the diffusion of the drug.

By using prescription records, the Coleman study was
able to accurately determine the rate of adoption and the
manner in which the drug diffused whereas most other similar
studies relied mainly on physicians' own accounts of their
adoption behavior. In a summary chapter, Coleman did state,
however, that "in broad outline and in many details, these
findings are similar to those obtained by other

investigators who relied on physicians' own accounts of what

led to their adoption of new drugs.” (p. 135)

49

When considering the actual diffusion of the new drug,
Coleman found that physicians' first use of the drug was
usually followed by continued use. Not only did the
cumulative proportion of doctors introducing the new drug
continue to increase, but the number of physicians using the
drug exclusively (as opposed to competing drugs) grew from 2
percent two months after introduction to 22 percent after 17
months after introduction. (p. 31) Those adopting the drug
earlier wrote relatively few prescriptions for it, thus
allowing for a trial period. Later adopters, presumably
relying on prior experience of their colleagues, tended to
prescribe the drug more often once they adopted it. This
cautious trail blazer phenomenon of the innovators has also
been demonstrated in the adoption of hybrid seed corn by
Iowa farmers. (Ryan, 1948)

Coleman found that there were indeed innovators
(early-adopters) and late-adopters of the drug and that
innovators of this drug were also innovators with other
drugs. Innovators as a group differed from late-adopters in
that they were more likely to be highly interested in
medicine as a science, to orient their work to others within
the profession (rather than to patients or non-medical
people), to have a broader orientation to sources of medical
knowledge in other communities, to be deeply integrated in
the local medical community, to select colleagues as social
companions, to have friends who are physicians, to belong to

a hobby club with other physicians, and to talk medicine

50
when with other physicians socially.

In a more subjective component of the Coleman study,
physicians' own testimonies were used to identify the
sequence of events that led them to try the new drug.
Physicians were asked how they first heard about the new
drug, where they learned more about it, if there were other
sources of information and which source was considered most
important. The results of the study indicated that 57
percent of the physicians identified drug companies' detail
men as being first to bring the news of the new drug, 18
percent said initial knowledge was received directly from
drug house literature, 7 percent identified professional
journals and 7 percent said they first learned of the new
drug from another physician. (Coleman, 1966, p. 54) Like
innovation adoption studies conducted outside of medicine
(Ryan, 1943), physicians did not adopt the new drug upon
initial exposure. In fact, only 10 percent started the drug
use after only an initial introduction while the remaining
physicians cited two or more sources (62 percent of these
cited three or more sources). (Coleman, 1966, p. 56) As
stated by Coleman (1966, p. 55), ”mere possession of
information concerning the availability of an innovation is
almost never a sufficient cause to explain its adoption:
information is not enough."

Although the concept of cognitive stages was not a
design element in this study, Coleman indicates that the

data does support the notion of stages as presented by Beal

51
(1957). Coleman (1966, p. 58) offers some justification for
the assumption that the order in which physicians were
influenced by the different media roughly relates to the
sequence of stages. If the data is viewed in this light,
then it can be seen that "The role of detail men and direct
mail drops with the passage of time, while that of
colleagues, meetings, professional journals, and drug-house
periodicals (house organs) rises.” (p. 64) This supports
the notion that there are at least two types of media:
those that "inform" and those that "legitimate.“ In this
specific case, commercial channels of drug company detail
men and direct mail tend to inform while the professional
channels including colleagues, meetings, and journals
legitimate.

Unlike other findings of innovation-adoption discussed
earlier, this study suggests that both innovators and
later-adopters go through the same decision-making process
influenced by the same sequence of channels of influence.
Innovators simply go through these sequences at a greater
rate of speed.

A large component of this study consists of developing
sociograms of social and professional relations among
physicians. From such an analysis, it can be demonstrated
that the diffusion of this new drug was a function of sets
of physicians acting as communities and not merely as
aggregates of unrelated individuals. (p. 130) Given this to

be true, it can be seen that the new drug diffused through

52
the social system in several stages. Initially, those
physicians with many professional interpersonal
doctor-to-doctor relations were adopters. Next were the
physicians tied together through a more socially based
network of friendships. The third stage of diffusion
involved the relatively isolated physician. The final group
of physicians adopting the drug were those who acted
independently of the time that their associates had
introduced the drug, thus social influence ceased to be
effective.

From this study it can be seen that the diffusion of an
innovation, at least this new drug, is a result of various
factors including attributes of the physician's practice,
physician's background, exposure to different channels of
communication, professional outlook, and doctor-to-doctor

relationships.

Will
The focus_of Geertsma's (1982) study was to identify a

mOdel characterizing changes physicians make in their
treatment of patients. This was accomplished by conducting
semistructured interviews with 66 physicians representing
five specialty groups: general practice, internal medicine,
pediatrics, obstetrics/gynecology, and surgery. The study
was designed to determine the ways physicians make changes
in their practice behavior by identifying stages in the

change process, information sources, and factors influencing

53
change.

Geertsma defines practice behavior as "any recurring,
patterned aspect or segment of the physician's thinking and
actions in practicing medicine.“

Initially a hypothetical model, constructed by the
author, was used to base the interview questions. The model
included the following steps:

Ptiming--the physician feels dissatisfaction with

some aspect of his practice behavior.

Ensnsing--the physician becomes aware of alternatives
or new practice behavior.

.Bationalization--the physician envisions solutions
to any practical problems associated with the

potential change.

Tziggotino--the physician responds by implementing a
change after a clear communication regarding the
desirability of the change.

Eyaiuation—-after making the change, the physician
assesses the practical results.

The results of Geertsma's study indicated that a
distinct change process over time, as proposed by his
hypothetical model, was not entirely discernible. The first
two stages, priming and focusing, were identified quite
consistently. ,The latter was most consistent and provided a
basic point of reference. The rationalization stage was
present but could not be fixed at any one position in the
change process sequence. Triggering was identifiable when
it occurred; however, physicians did not frequently
implement a change after an initial clear communication of a
possible change. Evaluation was rejected as a stage of the

change mOdel because it lacked discrete time boundaries and

because physicians did not generally make a conscious

54
determination of the value of a change. According to
Geertsma, “The physicians were simply not critical of the
changes they made." It was also found that following
initial exposure to a possible change, physicians generally
entered a period of further thinking about the change before
acting. Consequently, a new stage called foliou;uo was
added to the change model.

Following revision of the change model and final
tabulation of results, Geertsma's determination was “that
each stage in the model might play a part in some changes,
but the sequence of priming, focusing, and follow-up
constituted the heart of the change process.“ These results
suggested that different types of changes influenced the
number of stages identified. If the number of stages
identified can be related to the complexity of the change
type, then it was concluded that management changes are most
complex, followed by drug use and patient relationship. The
least complex were diagnostic, administrative and
educational changes.

For both the focusing and follow-up stages, the
agencies of change or information and advice sources were
identified. They included colleagues, journals,
conferences, Continuing Medical Education (CME) programs,
drug company representatives, and patients. Results
indicated that journals and colleague communication were the
roost important agencies of change. Colleague communication

‘was especially important at the follow-up stage.

55

S E I E l' i C . I' C] 1

Various aspects of the innovation-decision process with
respect to sources of information and communication channels
have been investigated within the medical field. These
studies can be loosely correlated with Rogers'
innovation-decision model.

Christensen (1979) examined pediatricians and
physicians practicing in a health maintenance organization
(HMO). The source of first knowledge for two new drugs was
identified and found that for one drug, colleagues were most
influential, while drug company representatives were
identified as most important for the second drug. Sources
used by physicians for general drug information were
uniformly found to be literature-based. Colleagues were
most influential in persuading physicians to adopt a new
drug.

Fineberg (1978) studied the dissemination of three
medical findings among 354 anesthesiologists. The major
source of information for one of the new medical findings
was journal articles but for the other two, the importance
of published papers was equalled by colleagues.
Additionally, physicians were just as likely to change in
response to a new finding whether they learned it from
published papers, colleagues or continuing education
courses.

A study of internal medicine house staff (Weinberger,

56
1982) as they incorporated preventive medicine into their
practice identified sources of information related to the
decision to change. Reading was found to be more
significant an influence than any other information source
including peers.

Manning (1979) studied how cardiologists first learned
and continued their education in echocardiography. Results
indicate that the printed page and self-instruction were the
most important means of medical education for both stages of
the innovation-decision process. Meetings and conferences
were the next most important sources followed by discussion
with colleagues and then courses. In a second study,
Manning (1980) investigated how 449 general internists first
learned the clinical principles of a particular drug and
also how they updated their information. Medical journals
were the most common sources of information at both stages
of the innovation adoption process. In descending order,
the next most popular sources were Continuing Medical
Education programs and discussion with colleagues, Modioai
Lottat, pharmaceutical company representatives and then
hospital rounds. In comparing the two studies, Manning
concludes that “physicians may use different sources
according to the complexity or applicability of the
information.“

Harelik (1975) found physicians rated professional
journals and the Physicians' Desk Reference (PDR) as the

best sources of drug information, and Smith's (1975) study

57
found that physicians depend primarily on journals and texts
for drug information. Stinson (1980) studied how physicians
stay abreast of current advances in medicine and found that
the use of various information sources was related to
factors such as type of practice, specialty, location of
practice, physician's age, and the size of the physician's
primary hospital. This study showed that medical literature’
was the most common source of information. Other
information sources included one to five hours each week in
discussions with colleagues, five to ten hours each year at
local professional meetings, five to ten hours per year at
state meetings, 10 to 15 hours per year at national
meetings, and 10 to 15 hours per year at medical school
sponsored educational courses. In a study whose purpose was
to follow the dissemination of new information (Stross,
1981), medical journals were the most common sources of

information.

I E l' E . 'I' i fl|.]. I'

Like so many other areas in this highly technical and
rapidly changing age, the knowledge explosion, coupled with
advances in communication, has created both tremendous
benefits as well as some dilemmas. One such problem area is
the acquisition and utilization of knowledge by physicians.
The increasing quantity of literature alone is staggering
(Durack, 1978) and illustrates some of the problems

physicians face in their lifelong learning efforts. Price

58
(1963, p. 8) describes the exponential growth rate of
scientific literature to be about six to seven percent each
year, thus doubling in size every 15 years. Additionally,
Warren (1981, p. 20) demonstrates the tremendous growth in
biomedical serials by citing that 70 years ago there were
only 1,000; 50 years ago, 1,500, 30 years ago, 4,000; ten
years ago, 14,000; and currently there are more than 20,000
journals. At present the National Library of Medicine (NLM)
collects approximately 3,000 journals published throughout
the world and indexes them in the computerized Medical
Literature Analysis and Retrieval System (MEDLARS). (BRS
Database Guide, 1982) This database contains about
3,600,000 documents with a monthly increase of 20,000
citations.

The problem for the physician is not just one of
learning new information. It involves considerably more
effort. Physicians must acquire a source of information,
determine what is applicable to his or her area of medicine,
and decide whether or not the information is useful in their
practice. Critics maintain that one major problem is that
much of the literature is poorly researched and written.
(Rutstein, 1961) Also there is the problem of a certain
bias created when manufacturers promote products and take an
active role in physician education. (McLaughlin, 1965;
Avorn, 1982) This requires the physician to make judgments
concerning the usefulness, value, and validity of others'

work. The remaining problem is that of incorporating the

59

acquired knowledge into practice.

Summary

While various attempts have been made both in the
communication and continuing education fields to identify a
conceptual framework which integrates learning behaviors
with a change process, no confirmation of a model or
consensus of opinion has yet been developed.

Much of this work done in the area of information
source, communication channels and stages in an
innovation-decision process addresses the topic in such a
way that the physician tends to be the target of information
dissemination efforts rather than the object of
investigation. Consequently, these studies tend to focus on
the mechanics of diffusion rather than a conceptual
framework built around the physician as a learner. For
instance, there is often no effort to differentiate how a
physician obtains information and what influences the
deciSion to adopt or reject an innovation.

It is the intention of this study to focus on the
physician as a learner. It is important to view the
physician in the context of adult learning theories in
association with the communication process, innovation
diffusion studies, innovation-decision models, medical
innovation models, and the magnitude of knowledge to be
learned. Additionally, various sociological and

psychological considerations must be taken into account in

60
an effort to gain a holistic view of the physician as a

learner in the change process.

CHAPTER III

METHODOLOGY

Introduction

The purpose of this study is to identify physicians'
learning activities associated with changes made in their
practices. This is not a highly tangible area of study nor
is the information sought at an easily identified,
superficial level. For these reasons, grounded research was
selected as the research methodology. This methodology
provides for the necessary flexibility and sensitivity in
data collection needed to identify physicians' change
behaviors. Little work has been done in this area;
therefore its study requires an open investigation, one that
looks for new information and insights rather than verifying
preexisting notions. From conclusions and hypothesis
identified as a result of this study, further research can
be initiated to verify, more quantitatively, the findings
here.

This chapter will first describe the theory of grounded
research and the interview as a research tool. Secondly, it
will describe the study population and outline in detail the

methodology used in this study.

61

62
WW

Grounded research, as described by Glaser and Strauss
(1967), Schatzman and Strauss (1973), and Glaser (1978) is a
sociological method of discovering theory from
systematically obtained and analyzed data. The basic
concept about which grounded research centers is that it is
the data that both initially provide direction and
continually shape and modify the research. That is,
conclusions, hypotheses and theories are developed directly
from the data obtained in the area of study. This method
provides the first step in discovering what concepts and
hypotheses are relevant for a given area. Grounded theory
differs from the traditional logico-deductive theory in that
the latter is a process of verifying preconceived or "a
priori“ assumptions. Grounded research provides a process
for identifying theories which are derived directly from the
data.

The grounded research method is a conceptual process
used to develop theory from data.

Generating a theory from data means that most
hypotheses and concepts not only come from the data,
but are systematically worked out in relation to the
data during the course of the research. Generating a
theory involves a process of research. (Glaser and
Strauss, 1967, p. 6)

Glaser (1978) has summarized and expanded upon previous
works to provide a basic outline for conducting grounded

research but cautions that there is no exact step-by-step

procedure that must be followed. The following concepts are

63
essential components of grounded research. They may take on

various forms in their execution.

D . I' C l

A grounded research study begins with an orienting
concept or perspective which can be considered the problem
area. By design this focus is vaguely defined, thus
allowing for modification once data collection begins.
Initial entry into a research field must be done with as few
predetermined ideas or 'a priori hypotheses" as possible.
This allows for conceptualizing and conceptual ordering of
the emerging data into a body of theory, unencumbered by a
preconceived theoretical framework.

Beyond the decision concerning initial collection
of data, further collection cannot be planned in
advance of the emerging theory (as is done so carefully
in research designed for verification and description).

The emerging theory points to the next steps. (Glaser
and Strauss, 1967, p. 47)

I] I' J S J' .

Theoretical sampling is the process of data
collection for generating theory whereby the analyst
jointly collects, codes and analyzes his data and
decides what data to collect next and where to find
them, in order to develop his theory as it emerges.
This process of data collection is controlled by the
emerging theory. (Glaser, 1978, p. 36)

As data is obtained, it is grouped into conceptual
categories. Through a process known as comparative
analyses, data from within the same study group or from
another group is viewed in relation to the developing

conceptual categories. Saturation occurs when all aspects

64
of a category have been identified and further data fails to
reveal new properties of a category. The result of
theoretical sampling is to elevate the data to a conceptual
level where a few concepts represent an array of data.
Grounded theory is based on the discovery of conceptual
categories and their interrelationships, not upon individual
facts. From these categories and the abstractions which
develop from them, the central theoretical framework or core
theory emerges.

Theoretical sampling involves both inductive and
deductive logic. Initially, grounded theory is induced or
drawn from data after data collection begins. Once
conceptual categories are formed, the direction the research
takes is deductively determined. At this point the
developing theory guides further data collection. Herein
lies the flexibility and sensitivity of grounded research.
At any time in the research a shift of plan or emphasis can
be made. As more information is revealed the researcher is
able to use that information to guide the research. This
enables the researcher to identify what is actually
occurring in the field and to pursue new areas of interest
while the research is ongoing.

Generating theory and doing social research are
two parts of the same process. How the analyst enters
the field to collect the data, his method of collection
and codification of the data, his integrating of the
categories, generating memos, and constructing
theory--the full continuum of both the processes of
generating theory and of social research--are all

guided and integrated by the emerging theory. (Glaser,
1978, p. 2)

65
C I' E J .

Comparative analysis is that part of the theoretical
sampling strategy that involves the systematic choice and
study of several comparison groups. This requires either
examining the same group in a variety of instances or the
same category in multiple groups. Initially the need for
comparative analysis is to validate facts. The replication
of data in a variety of settings and conditions is necessary
to confirm data so they can contribute to a conceptual
category. Secondly, comparative analysis can help establish
the structural boundaries of facts, thus increasing the
categories' generality and explanatory ability.

The basic criterion governing the selection of
comparison groups for discovering theory is their
theoretical relevance for furthering the development of
emerging categories. The researcher chooses any groups
that will help generate, to the fullest extent, as many
properties of the categories as possible, and that will
help relate categories to each other and to their
properties. (Glaser and Strauss, 1967, p. 49)

Comparative analysis also requires that additional data be
constantly viewed in relation to existing data and to
conceptual categories.

Two basic kinds of theory can be generated by
comparative analysis. Substantive theory is developed from
one empirical area and is limited to that specific area.
Concepts identified in a substantive area describe that
setting and concepts associated with it. No generalization

is made from one situation to another. Formal theory, on

the other hand, is developed from a conceptual area. It

66
transcends substantive areas, again using comparative
analysis to identify conceptual qualities from a variety of
areas. A close relationship exists between the two types of
theories in that concepts identified in various substantive
areas are drawn together to form formal theory. Hence both

substantive and formal theories are grounded in data.

TI |' J S | l'

Saturation occurs when instances of a category
repeatedly appear and no additional data are being
identified that can develop properties of the category. At
this point data concerning the same category must be
identified in other groups until the repetition occurs once
again. By maximizing the differences in groups, the
varieties of data concerning a category will increase, thus
developing many diverse properties of the category.
Achieving theoretical saturation can occur at most any time
during the research, making it impossible to predict at the
onset of the research how many subjects within a group and
how many groups will be sampled. Theoretical sampling based
on saturation of categories differs significantly from
statistical (random) sampling in terms of what is considered
an adequate sample.

Theoretical sampling is done in order to discover
categories and their properties, and to suggest the
interrelationships into a theory. Statistical sampling
is done to obtain accurate evidence on distributions of
people among categories to be used in descriptions or

verifications. (Glaser and Strauss, 1967, p. 62)

Theoretical sampling requires that the groups used for

67
saturating categories be as diverse as possible.
Statistical sampling, however, is dependent on techniques of
random and stratified sampling. Such sampling is not
necessary for theoretical sampling as the purpose of
grounded research is not to demonstrate magnitude of

theoretical relationships or an ability to generalize.

C i' i D I E J .

The purpose and design of the grounded research
methodology is to generate a set of categories and their
properties which can be integrated into a theory. In such a
metholology where the emerging data controls the direction
of the study, the key element is the coding and analysis of
the data.

Coding refers to a process of isolating the data into
individual indices or concepts and reorganizing them into
conceptual categories. Thus, coding provides an important
link between the data and theory formation.

Coding gets the analyst off the empirical level by
fracturing the data, then conceptually grouping it into
codes that then become the theory which explains what
is happening in the data. Coding for conceptual ideas
is a sure way to free an analyst from the empirical
bond of the data. (Glaser, 1978, p. 55)

Codes provide a condensed, abstract view of the data. This
conceptual scope allows the researcher to transcend the
empirical nature of the data.

Glaser (1978) describes two types of codes:

substantive and theoretical. Substantive codes

conceptualize the empirical substance of the findings. The

68
objective is to code different incidences or behaviors into
as many categories, both new and old, as possible. In doing
this the core relevancies emerge and provide direction
through the process of theoretical sampling. Theoretical
coding refers to identifying how substantive codes relate to
each other. Like substantive codes, theoretical codes
emerge during the research. It is from these codes that
conclusions, hypotheses and theories are formulated.
Theoretical codes provide an integrated scope, a broad
picture and new perspectives.

Another important step in the coding and analysis of
data is the writing of memos. Menos are a way to store
ideas and can be written from the very beginning of data
collection to the end of the research. Memos can be done on
any aspect of the information seeking process including the
related literature, the actual data and even from previous
memos. Memos can be viewed as either theoretical or
methodological. Theoretical memos represent ideas about
codes and their relationships to each other, categories and
developing theories. Methodological memos concern
strategies, techniques and tactics of the research. It is
the theoretical memo that elevates the data to a conceptual

level.

W
The purpose of grounded research is to generate theory

that accounts for behavior observed in the area of study.

69
Grounded theory provides explanations rather than validating
preexisting assumptions. The result of the grounded
research methodology is to conceptualize data, thus raising
the level of thought to a higher plane where a few concepts
indicate a large array of independent incidences. Grounded
research produces a stable, well substantiated theory.
Glaser and Strauss (1967) contend that:

Theory based on data can usually not be completely
refuted by more data or replaced by another theory.
Since it is too intimately linked to data, it is
destined to last despite its inevitable modification
and reformulation. (p. 4)

Glaser (1978) lists four criteria that grounded theory
should meet which enables it to be of practical use. First,
the categories must "fit” the data. That is, data should
not be forced or selected to fit pre-conceived or
pre-existent categories. Nor should data be discarded in
favor of keeping an existing theory intact. To accommodate
the emergence of differing data, categories must be
constantly reviewed. 'Our position is that the reality
produced in research is more accurate than the theory whose
categories do not fit, not the reverse”. (p. 4)

Grounded theory must also "work." By this Glaser means
that the theory must be able to explain what happened,
predict what will happen and interpret what is happening in
a research area. This is achieved by the systematic and
analytic approach of grounded research.

Thirdly, grounded theory must also be 'relevant." The

theory must reflect what is actually going on in the

70
research area. Relevance is achieved because the
methodology allows core problems and processes to emerge.
Modifiability is the fourth of Glaser's criteria.
Theory must be able to change as data continues to be
collected. Theory is an ever-developing entity. It is not
a perfected product. As the world changes and hence the

data, so to must the theory be modifiable.

W

The actual tool used to collect data in a grounded
research study has a significant influence on both the
process and outcome of the research. For this reason it is
important to describe the data collection method and
identify how it relates to other components of the study.
Personal semistructured interviews were used as the data
collection tool in this study.

An interview is a purposeful conversation. It involves
both verbal and nonverbal interactions between two people
who are working toward a common goal. (Fenlason, 1962) Its
primary function as a research tool is to gain information
and acquire insight. Gorden (1980, p. 5) states that
“Interviewing is most valuable when we are interested in
knowing people's beliefs, attitudes, values, knowledge, or
any other subjective orientations or mental content.“ The
personal interview was chosen for this study because, when
compared to other data collection methods such as

participant observer or pure observation, it provides data

71
within a relatively short period of time, encourages greater
participant participation and it lies within reasonable
limits of accessibility to the research field.
Additionally, the interview method is useful in a grounded
research study because of the flexibility it offers. For
instance, the interviewer can identify and pursue areas of
interest while conducting the interview. The personal
interview is not locked into a rigid predetermined
structure. Also, the direction and/or scope of the study
can be altered from one interview to another. Other
advantages include an opportunity to motivate the respondent
to supply accurate and complete information during the
interview, to guide the respondent in his interpretation of
the questions, to gain greater control over the interview
situation and to provide the interviewer a greater
Opportunity to evaluate the validity of information by
observing the respondent first hand.

Conducting a series of interviews requires the
interviewer to have an understanding of three basic areas:
the influence of an individuals background, their view of
the world and the social role they occupy in the social
system; the facilitators and inhibitors of communication
which interact during the interview; and interview
strategies, techniques and tactics used to gather meaningful
and valid data. The researcher's understanding and
abilities in these areas will greatly influence how the

research is designed, the various directions and forms it

72
will take while in progress, and the way the data is
collected and interpreted. Furthermore, both the researcher
and study participant's behavior must be viewed with respect
to these areas. The interview is a two-way conversation,
the behavior of the interviewer, data collection methods,
direction of the interview and data analysis must all be
viewed in the same conceptual context of culture and customs
as is the behavior of the participant. The interview is a
dynamic interchange where each individual's behavior is
shaped by the others and by all those influencing forces

acting on each person.

E l i J'I i i l . i J

Baokgtounds. Each person's background is shaped by
individual differences in heredity, environment,
experiences, culture and customs. An interviewer must
strive to understand and accept peOple of varying
backgrounds so that individuals' backgrounds can be a
contributing factor in the understanding of the subjects'
behavior. Likewise, the interviewer must be aware of his or
her own background as it effects the process and
interpretation of the study.

People's lives represent accommodations to cultural
patterns and standards traditionally held by society.
Culture influences individuals' lives through the impact of
other's behavior upon them and by imitation and instruction

of others. Fenlason (1962, p. 52) has outlined nine

73
concepts of culture which are applicable to an individual's
life:

1. Every culture is of paramount importance to its
possessor. It is alien only to those of other
cultures.

2. To understand individuals in another culture it is
necessary to have some appreciation of their
culture.

3. One who functions in a culture is part of it, and
every phase of his life and thought reflects that
culture.

4. Behavior may be a response to distant rather than
proximate stimuli.

5. A knowledge of the specific conditioning to which
an individual has been subjected shows the
functional relationship of things which are not
logically related.

6. One can be physically and geographically in a
culture and yet not psychologically in it.

7. In order to understand present behavior we must
view it as a cross section of the past.

8. If we know past behavior, we can predict certain
types of present and future behavior.

9. All our worlds are self—complete and
self-contained; clashes and discord are part of
normal functions.

The interview lies within the context of these concepts and
must be viewed in relation to them.

Personalif¥_and_8ehaxiof. A person's personality and
behaviors which express that personality are those
significant features of an individual which repeatedly
occur. The personality of both the interviewer and subject
have an influence on the interview. Fenlason (1962, p. 98)
describes ten generally accepted ideas of personality and
behavior which are useful to the understanding of the
interview method and data analysis.

1. The individual is a human being who functions in

and is conditioned by his environment and his

life's experiences.
2. Emotional needs take priority over reasoning.

74

3. Behavior is symptomatic, purposeful, and in
response to our inner needs and strivings.

4. Behavior can be understood only in terms of our own
emotional and intellectual acceptance.

5. Constructive, lasting results ordinarily come from
satisfying, successful experiences.

6. There is a tendency to be what others consider us
to be.

7. Behavior may be symptomatic of a serious disorder
in the body of society as well as an individual
failure to adjust.

8. A person cannot achieve his potentialities unless
his fundamental needs--physical and emotional--are
cared for.

9. Ideas become active only when charged by the
desires and inner needs of the individual.

10. Modification of behavior results from facing the
limitations imposed by the reality factors of any
situation.

.Rolo. A social role represents the way in which an
individual behaves within a social context. Behavior within
a role is controlled or at least influenced by societal and
institutional factors and conditions, and by physiological
and psychological forces within an individual. As a result,
a range of perceptions and expectations develops which
defines an individual's performance of specific activities
and tasks. Social roles are related to one another. Not
only do expected role performances demand expected behavior
but also roles can dictate behavior of others toward a role.
Social roles are learned during an individual's life and are
constantly modified and reordered. In an interview
situation both the interviewer and subject occupy certain
roles within the context of the interview. Also, each
member of the interview brings a host of behaviors which are

a result of conditioning from the many roles each occupies.

75
E 'J'I I . i'I l'l'l E C . I.

By nature of the interview method, it is highly
dependent of the ability of both the interviewer and subject
to communicate with one another. Although the subject has
agreed to participate in the study, it is primarily the
responsibility of the interviewer to see that the interview
yields meaningful and valid data. To do this the
interviewer must be aware of those conditions, actions and
behaviors which either help or hinder communication. This
knowledge must then be used to structure and control the
interview in such a way as to maximize valid data
collection. Gorden (1980) has described eight inhibitors
and eight facilitators of communication which influence the
interview. While being able to totally control or influence
each of these influencing factors is not possible during the
interview, it is at least important to acknowledge their
presence.

inhibitots. The first four inhibitors of communication
tend to make the respondent unwilling to give information.
The remaining four tend to make the respondent unable to

give information even though willing.

1. W The respondent feels
there are other ways he should or would like to
spend the interview time. The interviewer does not
necessarily place a negative value on being
interviewed, there are just competing demands.

2. Eoo_tntoat. The respondent withholds information
when his self-esteem is threatened. This could
lead to the respondent hiding information, being
afraid of interviewer disapproval, not admitting an
anxiety (even to himself) or fear of losing
status.

76

3. Etiouatto. People differ from one another in
their roles and status in society. This creates a
certain selectivity of information flow which can
inhibit communication both up and down the status
hierarchy. Both the nature of the situation as
well as the relationship between individuals can
inhibit communication. It is not always appropri-
ate to say the same thing in any situation to any
individual.

4. Txauma. A particular situation or topic may be
associated with an acutely unpleasant crisis
experience and hence cause the subject to either
consciously of unconsciously withhold information.

5. Foiootting. The respondent is unable to recall
certain types of information, particularly when
dealing with facts of the past. This loss of
memory may be hastened by selective psychological
repression which makes it easier for the
ego-defense system to reconstruct the past by
simple ommission, addition or distortion.

6. Cutonoiogioal_oonfusion. The respondent confuses
the chronological order of his experiences. This
can happen either by confusing the sequence of
events or incorrectly assuming that one condition
or event was true at an earlier point in time.
Here there is a tendency to utilize hindsight in
interpreting events of the past.

7. Infotontia1_oonfusion. Respondents may make an
error in induction when asked to convert concrete
experiences into higher level generalizations or
may err in deduction when given concrete examples
of certain types of experiences provided by the
interviewer. Two sources of either type of error
are the respondent's failure in abstract logic and
a distortion of thinking which may be produced by
strong attitudes and preconceptions.

8. flnoonsoiouo_oohaoiot. Information about a per-
son's behavior which is not consciously directed is
difficult to obtain. This behavior may result from
custom or having subliminal responses to cues from
others or from acute emotional stress where
behaviors deviate fron normal patterns.

aniiitatots. The facilitators of communication are
those actions, behaviors or human phenomenas which can
influence the social-psychological forces of an interview in
a positive way. The interviewer may both take advantage of

these facilitators as they just simply occur or in some

77
instances manipulate them to increase the flow of relevant
information. The eight facilitators are:

1. Fulfillingooxoootations. This can be viewed as
the "power of positive expectations." It is the
responsibility of the interviewer to communicate a
general expectation of cooperation as well as a
more specific expectation of response to individual
questions.

2. Booognition. People need recognition and the
esteem of others and will perform for them. This
can be provided by the interviewer in a sincere way
during the interview.

3. animuistio_annsals. People tend to identify with
a high value or cause which extends beyond immedi-
ate self-interest. This internalized response
to some group value generally increases an individ-
ual's self-esteem. Understanding the respondent's
value system can allow the interviewer to take
measures to improve communication.

4- WW- Host People have few
opportunities to converse with a good listener.
The interviewer can use this desire to be under—
stood to improve communication.

5. Nou_oxo££1£n££s. People generally enjoy new
experiences. The novelty of the interview could
provide interest in the interview and stimulate
information flow.

6. Cathaxfiis. This is the process by which people
obtain release from unpleasant emotional tensions
by talking about the source of their tensions and
expressing their feelings. The interview provides
an opportunity for the expression.

7. Nooo_fot_moanino. People seek answers to ques-
tions such a "Where an I going?" Or "Why do events
happen as they do?" Often a psychological tension
(cognitive dissonance) develops in a individual
when encountering any incongruence of facts,
assumptions or interpretations.

8. Exttinsio_touatds. These rewards other than
those gained directly from the interview that
encourage the respondent's participation. For
instance, the interview may help solve a non-
related problem which interested the subject.

I I . ‘SI I . T i . i T I.
To insure that the interview is indeed a conversation

with a purpose, the interviewer must have a degree of

78

control over the interview. This control or manipulation
can be exerted to varying degrees and at three main levels
which are strategies, techniques and tactics. These
controls can range from being planned for in advance to
those which must occur spontaneously during the interview.

Sttatogios. The strategies used to develop a series of
interviews include some of the broader conceptual
considerations which are closely related to the basic
research methodology. Strategies include determining who
the interviewer will be and establishing the basic approach
taken during the interview. Many strategies can be
established at the onset of a study, however when using
grounded research, new strategies are formulated and old
ones modified along with the evolving research methodology.

IToohniouos. Interview techniques are those actions
taken by the interviewer to minimize the inhibitors and to
maximize the facilitators of communication. These may be
verbal or nonverbal in form and are employed during the
course of the interview. Some verbal forms used as
techniques are: providing definitions of terms, helping the
respondent understand the question, providing criteria and
facts to be used by the respondent in making judgments and
discovering the respondents' own contexts.

One crucial element of the interview is the posing of a
question by the researcher. Techniques used to improve the
communication of a question include using a vocabulary which

is understood by the subject and not loading the question in

79
favor of a particular response. Also the scope of a
question varies from a broad type which is useful for
identifying the chronology of personal experiences,
perceptions of facts and perspectives, to narrow questions
which tend to reduce ego threat. Questions can also be
open-ended or closed. Open-ended questions are more useful
in discovering unanticipated responses, perspectives and
hierarchy of values. Closed questions are useful when
identifying specific facts. Closed questions tend to have
motivational value in that they shorten the interview, thus
reducing the problem of competing time demands. In any
case, when structuring the questions, the interviewer should
consider the type of information being sought as well as the
effect upon the respondent.

Nonverbal communication, although not easily
identified, does have a significant effect on the
information flow during a face-to-face interview. Nonverbal
communication tends to produce direct and immediate
responses which circumvent the conscious deliberative
process. Interviewers must develop techniques which
increase sensitivity to nonverbal cues from the subject, be
more aware of interviewer nonverbal messages and learn to
control those signals. Gorden (1980) has described four
modes of non-verbal communication which most nonverbal cues
fall into.

1. Exoxomioa communication is the use of interper—

sonal space to convey meaning. The distance
between individuals or between microphone and

80

subject should be controlled so that the
positioning is not too close or far away.
Positioning varies depending on different subjects,
sex combinations and age variations.

2. Ontonomios communication is the use of time in
conversations to convey meaning such as feelings,
attitudes and desires. The interviewer can control
for example, his own rate of speech (pacing) and
length of pauses between responses (silent probe).
The silent probe is likely the most useful of the
nonverbal techniques.

3. Kinssin communication refers to the use of body
movements to convey meaning. Such movements
include body posture, feet movement, hand movements
facial expressions and eye movements. The
researchers greatest use of kinesic communication
is with facial expressions and eye movements.

4. Zaxalingnifitio communication is the use of
volume, quality of voice, accent and pitch to
convey meaning. Altering any of these variables in
a sentence can markedly alter its delivery and the
way it is perceived.

Iaotios. Interview tactics consist of using the
appropriate order for the interview's statements, questions
and probes. Any behavior used as a tactic must be viewed in
a chronological context, that is, knowing what came before
and what is expected to come after the tactic. An
appropriate question or probe used at one point in an
interview may have an entirely different effect at another
time. The degree to which tactics can be planned in advance
depends on the type of information sought, the setting of
the interview and the amount of information desired. As an
example, the probing question is a common tactic used when
seeking further information or clarification. It is a
tactic that cannot be planned in advance. A second useful
tactic is the informal post-interview which is a short

relaxed discussion after the formal interview. This tactic

81
has two main uses. Firstly, it is used as an ego-builder
designed to leave the subject in a good mood. Secondly, it
can be used to detect inhibiting effects of the formal

interview.

8 J' lil'l , i n J'i'l

Reliability refers to the probability that an
observation can be repeated either at a different time or at
the same time by a second competent observer and give the
same results. Validity refers to the extent to which the
data conform to the facts. A relationship exists between
reliability and validity in that the reliability of the data
can be perfect but the observations may be erroneous. For
instance, the respondent may consistently either
intentionally or unintentionally provide misinformation.
Consequently, if observations are to be valid, they must be
reliable, but reliability does not guarantee validity.

The problem in proving validity in a traditional
logico-deductive methodology is that most observations of
behavior are indirect. Consequently, validity of the
indicator must then be demonstrated. Glaser (1967)
maintains that in a grounded research, validity can be
obtained by replication using comparative groups.
Furthermore, Glaser (1967) says:

...even if some of our evidence is not entirely
accurate, this will not be too troublesome; for in
generating theory it is not the fact upon which we
stand, but the conceptual category (or a conceptual

property of the category) that was generated from it.
(p. 23)

82

As long as categories are adequately saturated, the findings
will be representative of the circumstance or phenomena

being studied.

Methodolog¥_for_fhis_fifud¥
Grounded research methodology is a dynamic research
approach, integrating the problem area, researcher, subjects
and the study environment, all as part of a methodological
process. As the research evolves these classes of variables
are continually evaluated and redefined. The following is a
description of these variables and a detailed outline of the

research protocol.

W

Like other variables in this study, the nature of the
researcher plays an important part in the research process.
Although the data is systematically obtained and analyzed,
the interpretation and decision to proceed in any particular
direction is primarily a function of the researcher. The
researcher is a product of heredity, the environment and
past experiences. Additionally there are emotional,
economic, social and psychological forces acting on the
researcher. The researcher is not an unbiased, independent
third party whose presence in the study environment can be
dismissed. There must be some understanding of the
reseacher in relation to the study and an acknowledgment

that, like other research variables, the researcher is a

83
part of the ever evolving process of grounded research.

The researcher conducting this study is a 34 year old
Caucasion male born, raised and schooled in an
industrialized midwestern state. An undergraduate degree,
majoring in biology and minoring in behavioral psychology
was obtained in 1973 from a mid-size state university which
initially began as a teachers college. In 1975 a masters of
science was earned from a large urban state university.
During this time research training was essentially
quantitative in nature with some exposure to observational
field study.

Upon completion of the masters degree, employment was
obtained at a large community college located in the same
city where this research project is undertaken. At the
college this researcher is an instructor of human anatomy
and physiology. Additionally, some form of formal education
has been pursued on at least a part-time basis during this
teaching assignment. One learning activity undertaken
during this time was a partial completion of a nursing
program. Another experience involved a field study of the
educational activities at one of the local acute care
hospitals. Medical education was a primary focus of this
study. These experiences offered the researcher an
opportunity to experience a hospital clinical environment
and gain insight into the operation of a general acute care

hospital.

84
Inelastting

The research environment is an influential factor in a
study such as this one and must be considered when
identifying physicians' behavior. All the participants
involved in this study practice medicine in a medium size
midwestern industrialized city with an urbanized area
population of approximately 375,000 people (1980 census).
Four general acute care hospitals are located within the
study area with a total of about 1650 beds. Each hospital
has its own area specialization and there are varying
degrees to which each is specialized.

While none of the area hospitals are owned or managed
by a research organization such as a university medical
school, all are teaching hospitals. The hospitals, along
with a coordinating local medical education agency, provide
the last two years of clinical education for over 70 medical
students. Additionally, there are more than 250 residency
programs associated with the hospitals which prepare
physicians for state licensing and specialty board

examinations.

new

The study population consists of two allopathic
specialty groups, including nine obstetrician/gynecologists
and eleven internists. Within each group there are varing
degrees of subspecialization (Appendix B). All physicians

work in either solo or group private practice and have

85
admitting privileges in at least one of the area hospitals.
The age range of participants was from 32 to 58. All
physicians studied are Caucasian males with the exception of
one foreign-born English speaking Caucasian woman.

The study participants have, for the most part,
received much of their education and training in the state
where this study was conducted. About one half of the
physicians attended medical school in this same state.
Additionally, most of the participants received their
internship or residency training at one or more of the
hospitals in which these study subjects practice.

All physicians in this study are volunteer clinical
faculty for a state supported medical school. This clinical
program is coordinated and administered by a local medical
education agency. Volunteer teaching is done in addition to
a physician's private practice. The function of the
clinical faculty is to provide teaching and supervision for
medical students as they rotate through various specialty

areas.

13 I'E i ll 5| 3 E I. . |

At the onset of this study, the exact number of
participants and the specific groups involved was not
determined. As the research evolved the character of the
study population took shape. This is consistent with the
grounded research methodology.

Prior to any participant interviews, an interview was

86

conducted with an obstetrics/gynecology resource physician
who served as both the director of city-wide
obstetrics/gynecology programs for a local medical
educational organization and the program director for one of
the local hospital's obstetrics/gynecology residency
programs. The purpose of this orienting interview was to
gather general information about the obstetrics/gynecology
specialty. Data gathered during this interview concerned
areas such as:

1. What kind of work obstetrics/gynecology physicians

2. $3; kind of people who seem to be attracted to

this specialty.

3. Some history of the specialty group in the local
area.

4. Influencing factors such as social, political and

economic pressures that shape the specialty and
those in it.

5. What type of changes have occurred in the specialty
and how those changes have changed the specialty
and those who practice in it.

After completion of the obstetrics/gynecology interviews and
prior to interviewing any internists, a similar orienting
interview was conducted with an internal medicine resource
physician who, in addition to his private practice, serves
as director of medical education for one of the area
hospitals.

Obstetrician/gynecologists were the first physicians to

be invited to participate in this research project.
Initially 20 names were randomly selected from an

alphabetized list of 38 obstetrics/gynecology clinical

faculty and a letter of invitation was sent to each

87
(Appendix C). The purpose of the random process was to
acquire an even distribution of data collection within the
group rather than an effort to establish a basis for
generalizing research findings beyond the parameters of this
study group.

Along with the letter a self-addressed, postage paid
postcard was included for the physician's response. Those
physicians who responded positively to the invitation were
contacted by telephone and appointments were made usually
within a two week time. Physicians who did not respond to
the initial letter were sent a second letter once again
asking for their participation (Appendix D). Physicians who
chose not to participate and those who did not respond to
either invitation were not contacted again. For every
physician who chose not to participate, a new name was
randomly taken from the remaining names on the original list
of physicians. The same process of invitation and follow up
was followed for each of the replacement physicians until
the list had been exhausted.

Initially the format for recruiting internists was
similar to that used for obstetrics/gynecology physicians.

A list of 20 volunteer clinical internal medicine faculty,
consisting of an equal number of general internists and
subspecialists, was developed by the internal medicine
resource physician. These were physicians who the resource
physician believed would be willing to participate.

Invitations to participate were sent to each physician along

88
with a self-addressed, postage paid postcard. This letter
differed from that sent to the first group only in that it
identified both obstetrician/gynecologists and internists as
study subjects. Follow-up letters were sent to those
physicians who did not respond to the initial request to
participate. Approximately half of the internal medicine
participants were obtained in this way. Because of a low
positive response rate from the initial invitations and due
to time constraints the remainder of the internal medicine
subjects were obtained by personal request from both the
internist resource physician and the chief executive officer
of the local medical educational agency with whom this
research project is affiliated. Some of the physicians from
the original list of 20 internists were contacted again and
the remaining physicians were chosen and asked to
participate by the internal medicine resource physician.
These physicians were chosen based on perceptions of their

willingness to participate.

W

The semi-structured interview used in this study should
be viewed as a research tool that changes and evolves during
the course of the study. As the data reveal the nature of
physicians' learning activities associated with changes made
in their practices, the scope and direction of the inquiry
changes form. Consequently, the interview format changes to

accommodate new study pursuits. Thus the semi-structured

89
interview format served as a framework providing order to
the interview and at the same time retaining a degree of
flexibility. This allowed the interview to flow more as a
conversation than a question and answer dialogue. Using the
interview as a framework also allowed'for changing the order
and nature of topics discussed during the interview, to
consider time limitations, and to pursue topics of interest

during the interview.

Intotuiow_1nttoouotion. Each interview began with a
brief introduction which included information about the
interviewer, the nature of the research methodology and the
purpose of the study. This took about five minutes. The
essence of the introduction is as follows.

Thank you for your willingness to participate in
this study. I am a doctoral student in education at
(name of university) This study is part of my degree
requirements. One of my major areas of study has been
lifelong learning. I have been learning about how and
why adults learn in response to changes in their lives.
Specifically, my interest is in identifying the type of
learning activities physicians engage in when making a
change in their practice. I have chosen physicians as
a study group because the entire field of medicine is
well known for its rapid growth and it would seem that
physicians must have to make many changes to keep up in
their field.

The research methodology I am using is called
grounded research. Basically this approach begins with
an area of study, in this case, learning in response to
changes occurring in a physician's practice. During
the study, data is compiled and systematically
analyzed. As a result, conclusions and theories are
drawn from what is directly observed. In other words,
there is no theory that I am trying to prove or
disprove. There are no right or wrong answers. Your
input, answers and observations, are the data that will
form any conclusions or theories resulting from this
study.

Aside from my graduate studies I am also an
instructor of anatomy and physiology at (name of

90
college) and have had some hospital clinical
experiences. Please feel free to use your medical
language when talking about your practice. If you say
something I don't understand I will ask you to explain
further if necessary.

If you have no objections, I would like to tape
record our conversation so I can refer back to it at
some later date. I assure you that you will remain
completely anonymous. You have been coded with a
number so your name will not appear on any transcript

or final writing of this study. Do you have any
questions before we begin?

Dexelopmenflof_the_1nferxicwucomnonenfs

The development of the interview format was gradual and
based on previous interviews. Each interview presented new
information and more questions. The development of the
conceptual components was an effort to maximize data
collection, verify previous findings, and answer questions
resulting from earlier interviews. Hence, these components
changed form during the course of the study and different
aspects of each were emphasized at different times.

The first interview was loosely structured. The
physician was asked to identify a change made in his
practice and discuss how and why it had occurred. Due to
problems of recall and inability to structure his thinking,
the next interviews were structured into two conceptual
components. This inability to easily perform the task
produced behaviors such as looking at his watch, giving
abrupt answers, and becoming restless. These types of
behaviors were seen throughout the interviews and were used

by the interviewer as signals to change the course of the

91
interview.

The first component was designed to help the physician
identify the various changes which have occurred in his or
her practice within the last two years. There was no
attempt to develop a complete cataloging of each change type
which could then be used to compare one physician's
experience with another. It was determined that this was
neither feasible nor Productive in terms of understanding
physicians' learning activities.

Throughout the first eight interviews, as more was
understood about physicians' response to change, the need to
identify these findings in relationship to physicians' as
learners, their needs, habits, and motivations became
important. Hence the development of the third component.
This component evolved during the last several
obstetrics/gnyecology interviews and was fairly consistent
through the sixth internal medicine interview. At this
time, less effort was spent on components one and two and
more emphasis was placed on component three. For the
remaining internal medicine interviews, the third component
was further expanded to identify more about physicians'
information storage and retrieval systems. The emphasis
here was in understanding how and why information storage
and retrieval systems developed, to what extent they are
used, and in what way they influence learning associated
with changes made in practice.

In order to allow for a free and spontaneous interview,

92
a rigid sequence of interview components was not followed
during the interview. For instance, if a conversation moved
into another component area and was constructive, it was
allowed to continue. The purpose of the interview format
was not to impose a rigid control on the conversation but
simply to help give the researcher a way of structuring the
incoming data and to help move the interview in a positive
direction if necessary. Also, the order and emphasis on
individual questions within each interview component was not
strictly adhered to. These factors depended largely on the
physicians' interest, willingness, abilities, subjects being
discussed, and time.

Eitotointotxiou_£omoonont. The first component of the
interview was a cataloging of the various changes the
physician had made in his or her practice. This was done
initially to identify changes made by the physician and so
the interviewer could have several options for more detailed
discussions. The need for this structure was determined
during the first obstetrics/gynecology interview. Because
of the first physician's difficulty in identifying recent
changes, this portion of subsequent interviews was more
structured, reducing the difficulty of the physician's task.

Following the initial interview, eight change types
were presented, one at a time, to help organize the
physician's thoughts and stimulate recollection. The change
types were developed by Geertsma (1982) who, after

conducting interviews, identified changes made by physicians

93
and grouped them into eight classifications. These change
types are not mutually exclusive as some changes do fall
within several classifications. For each change type the
physician was asked to think of any change he or she had
made, regardless of its significance to the practice or
patient care. These changes were to have been made within
the last two years. The purpose of the time limitation was
to both help organize the physician's thinking and to
minimize problems with recall. It was specifically stated
that the change need not be the most important change made

in the practice. The eight change types are:

administrative/office procedure

drug use (new drug or new use of existing drug)
patient relationship and education

technical aspect of diagnosis

diagnosis approach

technical aspect of management

management approach

own education

mqambwwp

In the event the physician did not completely understand
what was meant by the change type, an example was given.
These examples are listed on a data sheet. (Appendix E) The
physician's understanding of the change type was determined
by observed facial expressions, length of time prior to
responding, length of response, patience, questions posed by
the physician, and by the appropriateness of the responses.
Brief notes were taken on a data sheet (Appendix E)
during this first component of the interview which enabled
the researcher to refer back to the change during subsequent

discussions. Some changes required short discussions for

94
purposes of clarification or to determine if pursuing the
change later would be useful. As the changes were being
listed and discussed, an indicator was placed on the data
sheet next to those changes which might be discussed in more
detail in the second part of the interview.

Following the last change type, several questions were
posed to identify the scope of physicians' exposure to
changes. First, physicians were asked to identify their
learning resources and indicate the order of importance to
them. Second, they were asked, ”Of all the new things that
you come across each year what percent of them do you
actually incorporate into your practice?" The purpose in
asking these questions was to get the physician to link the
specific changes just outlined with where these ideas come
from and put in perspective the changes they have made with
respect to the total mass of new information to which they
are exposed.

Sooond_1ntotxiow_comoonont. The second component of
the interview consisted of detailed discussions concerning
two or more of the previously stated changes. The number of
changes discussed depended on the nature of the changes,
time spent on each change, extent of the physician's
learning activities associated with the changes, the amount
of time available, and the willingness of the physician.

The decision to chose one change over another was based
on considerations such as:

l. The novelty of the change.

95

How long the change had taken.

The complexity of the change.

Bow closely connected the change was with other
changes made in the physician's practice.

If this particular change had been discussed with
other physicians.

How often the change is used.

Who made the decision to change.

How interested the physician seemed to be about the
change.

QQG U'I fiUN
e e e e

Some changes were chosen because they had been
discussed with other physicians. This helped to saturate
the research categories. Other changes were chosen to
contribute to research categories such as to what degree a
physician has control in implementing a change, how does
competition influence change, what affect medical—legal
problems have on making changes, and how varying degrees of
specialization influence change in a practice.

There was no predetermined criteria for deciding which
of the changes would be chosen for further discussion as
there was no way of predicting physician's responses. The
decision was made based largely on the intuitive judgment of
the researcher at the time.

At the beginning of each detailed change discussion,
physicians were asked to outline the sequence of events and
activities that led to making the change. To get the
conversation started, physicians were asked to go back in
their thinking to before they had any knowledge of the
innovation or change and to explain how they dealt with the
situation at that time. This question not only served to

establish a point from which to begin a discussion about the

96
change but it also provided a brief historical perspective.
Such a view was necessary for understanding why and how the
change was made. Following this response the physician was
asked if they were more satisfied, as satisfied or less
satisfied with that practice compared to all the other
activities in their practice. The purpose of this question
was to identify a motivation for making the change. Why did
the physician make the change? Was there an outstanding
problem that needed to be addressed or did the change just
happen to come along?

As the detailed description of individual changes
progressed, probing questions were asked when the
information was not volunteered, or to keep the discussion
centered on the subject. These probing questions were
initiated after the first interview. The wording and order
of these questions developed from each subsequent interview
during the first five interviews. From that point this
portion of the interview remained fairly constant. These
questions that developed do not represent the only questions
that were asked in each individual interview.

When did you first learn about the change?

How did you first learn about the change?

What prompted your first learning of this change?

Were you actively seeking the solution to a

problem or did it come about as part of your

routine of keeping informed and up-to-date?

5. Why did you happen to pick this particular change?

6. Did you acquire additional information after first
learning of the change?

7. What did you do to learn more about the change?

8. How long did it take you to decide to change?

9. When did you decide to change?
10. What influenced your decision the most to adopt the

thH

97
change?

11. From the time you decided to change to the time you
actually implemented the change, did you pursue any
learning activities? What were they?

12. What activities have you been involved with in
conjunction with this change since its adoption?

These questions were designed first of all to help establish
a sequence of events and activities associated with each
change. This helped to better understand the changes and
put them into perspective with the rest of the physician's
practice. Secondly, their purpose was to identify not just
the mechanism of change such as how and when, but also why
the change was made and what the physician's motives were
for making the change. In other words, why would the
physician want to change and go about the necessary learning
activities associated with making the change? Physician's
responses were recorded on the data sheet (Appendix E) for
use during the interview.

As more obstetrics/gynecology physicians were studied,
the form of the interview changed. With each interview, the
researcher became increasingly familiar with the type of
changes characteristic of the specialty. Consequently, less
time was needed for cataloging changes. This enabled more
time to be spent in detailed discussions of individual
changes. Additionally, as more data were compiled,
categories of learning and change behavior emerged. Each
additional interview was an opportunity to explore

properties of the study categories. When further data

collection did not reveal any new properties of the

98
category, saturation had occurred. At this point in the
research, the saturated categories, along with unanswered
questions, contributed to the direction of the study.

During the development of the interview questions, some
topics were initiated but eliminated after a first attempt.
For instance, in this component, an effort was made to
identify the significance to the physician of each change
discussed in detail. Five levels of significance, adopted
from Geertsma (1982) were used. They included:

1. physicians' convenience

2. patients' convenience

3. preferable treatment, not life-death involving

4. major system involved

5. life-death or morbidity directly involved
The purpose of doing this was to learn more about the change
and the physician's motivation for pursuing it. After using
these questions in one interview, it was determined to be
too time consuming, difficult to explain, and failed to
yield information that could not be obtained from other
parts of the interview.

The choice of categories, degree of saturation, and the
direction pursued were all decisions deductively derived by
the researcher. As a result of this grounded research
methodology, a third interview component was developed.

Thi£d_lnt££¥isn_£omponont. The third component of the
interview was initiated during the last two
obstetrics/gynecology interviews and continued to varying
degrees throughout the remaining interviews. This interview

component was designed to initiate conversation that would

99
reveal more information about the physician as a learner.
The core questions were:

1. When you read a journal, listen to a speaker or
interview a drug company sales representative, what
motivates you to pursue one of the many things that
you are confronted with?

2. Within the last year, what practice or activity
were you so displeased with that you actively
sought a change?

3. Think of all the different areas of learning that
you experience. List the major categories. For
instance: a) patient care and treatment
b) business aspect of your practice c) leisure
activity d) family e) personal growth.

4. Prioritize these categories in terms of the amount
of time and energy spent in each.

5. Do you set aside a time for learning? How much
time? When? What type of things do you learn
during this time?

6. Do you find that this amount of time just keeps you
caught up or are you able to pursue areas of
interest?

7. What are these areas of interest? Lately, what
have you pursued?

8. What motivates you to pursue learning in these
areas?

Initially, following question number four, physicians
were asked, “What percent of you as a learner does each
category make up?" This was not an attempt to quantify the
data but to simply give a clear view of the different areas
in which physicians learn. This proved difficult to obtain,
highly subjective. and failed to contribute meaningful data.

The extent of this inquiry was dependent on the time
remaining in the interview and the willingness of the
physician to participate.

The ninth obstetrian/gynecologist interviewed (Dr. 109),
was the last of the original 38 physicians who were invited

to participate in the study. In all likelihood a personal

100

appeal by an inside contact such as the
obstetrics/gynecology resource physician could have
increased the number of obstetrics/gynecology participants;
however, at this point in the study, the decision to change
study groups was made. The primary reason for the decision
was based on the need to broaden the research categories by
studying those categories in another group. By the ninth
obstetric/gynecology interview, the data were not revealing
any new properties of the original categories, thus
saturation had occurred. The secondary consideration was
that participants who first declined and then were prodded
into participating may have been less than willing subjects
and thus may not have contributed meaningful or sufficient
amounts of data to the study.

The series of internal medicine interviews paralled, to
a degree, those of the obstetrician/gynecologists. The
first several interviews focused on learning about the
physicians, the nature of the specialty and the type of
changes made in the specialty. Research categories and
their properties established during the
obstetrics/gynecology interviews were further investigated
to reinforce and expand those categories and to establish
new ones.

As the initial research categories within the group of
internal medicine physicians reached saturation, more
emphasis was given to the third component of the study.

Especially during the later interviews, this third component

101
was further expanded to identify physicians' routine
learning behaviors and to learn how they respond to being
constantly confronted by an ever increasing volume of
information. Typical questions concerning this area were,
”How do you store and retrieve information?" and "How secure
do you feel about the effectiveness of your information
storage system?“

Closinggthellnterxiew. The procedure for closing the
interview and the interview follow-up was the same for both
study groups. At the conclusion of each interview,
physicians were thanked for taking the time to participate
in the study and for being willing to talk about their
practice. At this point the audio-recording was stopped.
This was done to create a more casual and open environment
in case the recording was inhibiting in any way. Physicians
were then asked if they had any questions or comments they
would like to make. This part of the interview varied in
length depending of the physician's schedule and interest in

the study.

W

The follow-up procedure for each interview consisted of
a written post-interview note, a transcription of the
audio-recording and a thank you letter sent to the study
participant. The post-interview note included the
researcher's impressions of the interview such as the length

of time the interview took, the willingness of the subject

102
to participate, any particular attitude or environmental
condition worthy of noting and the ability of the
participant to answer questions. Additionally, data
collected after the audio-recording had stopped was
documented. These post-interview notes were written within
several hours of the interview. (See Appendix F for an
example.)

Each interview was documented to facilitate data
analysis and to insure accuracy of the reported interview.
At the beginning of each audio-recorded interview, the
researcher stated the date and the participants code number.
Throughout the interview the physician was not referred to
by name nor were there questions asked that would reveal the
identity of the physician. Following the interview the
audio-recording was transcribed by a typist and returned
within approximately one week. (See Appendix G for a
typical example of the transcription format.) Two
interviews were not audio-recorded, one due to recorder
failure and another at the request of the physician. In
both cases, detailed notes were taken during the interview
and a report was written directly following the interview.

Thank you letters (Appendix H) were sent in two groups.
The first set was sent following the obstetrics/gynecology
interviews and the second set following the internal

medicine interviews.

103

W

Upon receiving the typewritten transcript of the
interview. the data were initially analyzed to organize them
into the various developing research categories, to identify
new categories and to make notations regarding the direction
of the study. Notations were made directly on the
typewritten transcriptions. As the study progressed, the
data from each interview was compiled onto a single large
data sheet to help visualize and assess the data. This
helped the interviewer to see strengths and weaknesses in
the interview, trends in physicians' responses and provide
yet another way of looking at the data. As part of the
continuous process of data analysis, research notes were
written in addition to the initial individual interview
analysis. These notations were taken from all the data
collected and were both methodological, referring to how the
research was being conducted and theoretical, which involved
handling the findings of the study. The sequence of
research components and their development as outlined
earlier in this chapter are a result of this process of

ongoing notation and analysis.

E ]' I'Jil ’ i H J'i'l-
Reliability and validity of a study such as this one

are by the nature of the study difficult to demonstrate.

There are some aspects of the research methodology which do

contribute to reliability and validity; however, in light of

104
the type of research, neither consideration was of primary
importance to the study. There are aspects of the research
method that do contribute to the reliablilty of the findings
including:

1. All the interviews were conducted by the same
interviewer.

2. A consistent format was used for all interviews.

3. All interviews were well documented either by
audio-recording or by the researcher in written
form.

These factors deal mainly with the actions of the
researcher. In a study such as this, there is little
opportunity to observe the participants under the same
conditions.

There are two elements of the research which contribute
to the validity of this study. Firstly, the interviewer was
familiar with the biomedical language used by physicians.
This improved communication and understanding, thus allowing
the interview to progress more smoothly. Secondly, at
various intervals during the interview the researcher
confirmed the comments made by the physician by briefly

recapitulating the conversation. The physician then had the

opportunity to correct any misunderstandings or omissions.

CHAPTER IV

FINDINGS AND DISCUSSION

Introduction

The initial focus or orienting concept of this grounded
research study was to describe physicians' learning
activities associated with changes made in their practices.
It is from this point that the study begins and develops.
In a grounded research study such as this, the research
findings must be viewed not just as the end product of a
methodology but as influencing factors in an ongoing
research process. The results of one portion of the study
determines the direction of the ensuing research. Because
of this determinative nature, the presentation of the
findings in this chapter will be chronologically sequenced
and their influencing role as part of the research
methodology discussed. Presented in this chapter will be
the findings and discussion of the obstetrics/gynecology and
internal medicine resource interviews; the first
obstetrics/gynecology interview; the remaining
obstetrics/gynecology interviews, considered together as
components one, two, and three; and the internist

interviews, also presented collectively in three components.

105

106
WWW
Of the 38 obstetrician/gynecologists invited to
participate, 26 replied after the first or second letter of
invitation. Of those who responded, lO volunteered to
participate and 16 declined. One physician who volunteered
was out of state and would not be returning for six months.
Due to the time element this physician was not included in
the study. Although physicians were not asked to explain
why they declined to participate, several indicated that
they did not have the time or that their partner was
participating and felt that their participation would not be
necessary. One physician remarked, ' -- lately I haven't
had time to go to the john, let alone participate in a
research project.” Presumably the competing demand for time
was a major participation deterrent. Further evidence of
this was revealed during the interviews. Physicians often
commented on the fast pace of their lives. This became
apparent as the physicians described their practice. The
fact that most interviews were conducted during the
physicians' day off or after work hours also indicated that

these physicians have little spare time.

DI | | . CE 1 E El . .

The obstetrics/gynecology resource physician
interviewed prior to the participant interviews had a unique
vantage point in that he was both a practicing

obstetrics/gynecology physician and an obstetrics/gynecology

107
residency program director. This enabled him to view the
specialty both as a participant and as an observer. It is
from this perspective that the resource physician described
the nature of the specialty and character of those in the
practice. The essence of the interview is as follows:

The obstetrics/gynecology physicians in this town
are associated not just professionally but socially as
well. Physicians do interact professionally with
hospital affiliated functions and educational
activities but also belong to a local social
organization. This is a loosely structured group that
allows physicians an opportunity to get to know each
other and exchange information and concerns. This
social aspect of practice does have some influence in
that a person cannot just set up practice in this
community without considering the social environment.
There is a certain degree of networking and
relationship building that must be accomplished in
order to successfully practice in this town.

Obstetrician/gynecologists as a group range from
those who are rather conservative father-figure types
to those who see their role more as health
facilitators. Younger physicians seem to be coming out
of the medical schools with less of the fatherly
attitude. Also, society has changed somewhat in its
expectations of physicians.

Obstetrics/gynecology physicians are currently
subjected to several social pressures that are having a
significant impact on their practices. First, the
birth rate is not as high as it once was and there are
still many physicians. This has created a certain
degree of competition in the field. Second, the
medical—legal problem is particularly acute for
obstetrician/gynecologists as they are the most
commonly sued group of physicians. This creates many
pressures and very high insurance premiums.
Obstetrician/gynecologists are particularly vulnerable
to being sued because they are easy targets. Injury or
death of an infant, for instance, is a very emotional
situation and can easily be used to play on the
sympathy of a judge or jury. One scenario that
sometimes occurs is that a physician will lose a suit
and his premiums will increase. In order to offset the
increased cost, the physician must increase his patient
load which in turn increases his chances of making
errors and being sued again. This downward spiraling
eventually forces some physicians out of business.

Lastly, the resource physician discussed several

108

current changes in the field such as ultrasound, new

generation antibiotics and vaginal deliveries for

mothers who previously have had caesarean-sections.

Several information resources were discussed including

the Journal of Contemporary Obstetrics/Gynecology.

Following this interview a brief survey of the
obstetrics/gynecology literature was done to identify
current trends and innovations in the field. Several areas
of interest identified were: colposcopy, nuclear magnetic
resonance, electronic fetal heart monitoring, relating
biparietal diameter with,weight of the fetus, chorionic

villi sampling, cryosurgical units and carbon dioxide lasers

in obstetrics/gynecology surgery.

The results of the first obstetrics/gynecology
interview are presented apart from the others in this
specialty group because the methodology used during the
initial portion of the interview was significantly different
from subsequent interviews. Interviewing techniques and
tactics were often modified from one interview to another;
however, the greatest changes occurred following this
interview. While the volume of data generated during this
interview concerning specific changes is less than other
interviews, the interview did have an important influence on
the understanding of physicians' practices and the
development of a more effective interview format.

After an introduction and orientation to the purpose of

the study, Dr. 101 was asked to identify any changes made in

109

his practice within the last two years. It was stated that
these changes need not have been the most significant
changes made in his practice and that they could be as small
as, for example, changing the type of suture used for a
particular procedure. Dr. 101 had a difficult time
identifying any changes and after several moments of
contemplation began by saying, I'Well I guess the most
important change I have made within the last two years was
to ...' Dr. 101 also stated that it was difficult to
identify changes because of the gradual way in which most
changes take place in his practice. “Things just seem to
flow or blend in." These comments and others during the
interview made it apparent that the need to structure one's
thinking in order to improve recall and ordering of events
and actions places an additional burden on the physician.
This effort extends far beyond simple recall of single
events. There either did not seem to be the necessary
motivation on behalf of Dr. 101 to make the extra effort to
structure his thinking, to increase his recall, or it was
too difficult a task.

Three changes were identified during the interview:
the addition of a new partner to the practice, the purchase
of a new colposcope, and the practice of performing vaginal
child births on women who previously had caesarean-sections.
The purchase of a new colposcope was the first change to be
examined in detail. This purchase was the third in a series

of the same instrument used in the office, each being more

llO
versatile and sophisticated than the former. The physicians
in this group had been using this same colposcope at one of
the local hospitals so they were familiar with it and had
little difficulty when deciding to purchase a new one. Dr.
101 first learned of the colposcope in 1970 when he received
a brochure from a university medical school advertising a
course in its use. The first colposcope was purchased about
one year after this course was taken by Dr. 101. Continued
learning about the colposcope has been accomplished by
reading journals, talking with colleagues, using the scope
and by taking two additional courses, one in 1976 and
another in 1981. Dr. 101 said his motivation for making the
commitment to a new piece of equipment initially was
because, “that was the way things were going, so I wanted to
keep up." The incorporation of this technique into Dr.
101's practice has been gradual and seemingly at a pace
consistent with the development of the instrument and
technology.

The second and final change discussed in detail was the
procedure of delivering children vaginally with mothers who
had previously delivered via caesarean-section. This has
been a highly selective practice which has developed within
the last year. In the past the saying has been "once a
section, always a section.“ Dr. 101 first considered this
procedure after reading a growing number of journal articles
addressing the issue. “This seems to be in line with other

things like mirrors in the delivery room and father

lll
participation. The patients want this so we have changed to
accommodate.“ The physicians in Dr. 101's group practice
began very conservatively in implementing this change and
have continued based mostly on their own experiences but
reinforced by evidence in the journals.

As a result of this initial interview, subsequent
interviews were structured differently in order to improve
the quality and quantity of data. During this first
interview, changes were discussed as they were initially
mentioned. This allowed for little flexibility in guiding
the interview which tended to restrict data collection. To
remedy this problem and the difficulty of recall, the
interview was given more structure. Initially, two
components were developed, the first outlining the various
changes made and a second which examined several of the
changed in more detail. The purpose of the first component
was to divide the recall task into smaller, more manageable
units, thus providing the physician a more specific area
(change type classification) in which to focus. This also
gave the interviewer an overview of the various changes made
and an opportunity to select specific changes for the second

interview component.

DI | | . CG 1 I I . --E' I C I
Using the eight change type classifications (Appendix
E) to help physicians identify changes in their practice did

provide a large quantity of useful data. The total number

112
of changes identified per physician ranged from six to 23.
During this first component many of the same changes were
mentioned, although no one change was consistently
emphasized or shown a particular interest in over the
others. Each change was discussed only to the extent needed
for a basic understanding by the interviewer. As the
interviews progressed, less time was needed explaining each
change because many changes had been discussed in previous
interviews. The following is a brief outline of the changes
identified in each change type classification and related
significant observations.

.Admini5IIflii¥££flfifi££_££99£dn££. The type of
activities identified in this change type classification
were changes in billing, dictating patient notes and
progress records, cross referencing of diagnoses of
patients, increasing the office space, adding a partner,
hiring an office manager, hiring a personnel consultant and
patient scheduling.

The business aspect of a private practice was most
evident during this part of the interview. Since most
physicians interviewed practice in a group, there are varing
degrees to which they are involved in the business of the
practice. This involvement ranges from primary control to
none whatsoever. Several physicians expressed a lack of
preparedness, disinterest or dislike for this aspect of a
private practice.

Drng_flse. Changes involving drug usage were generally

113
the easiest for the physicians to identify. This is
probably due to the relatively high frequency of use. The
types of changes in drug usage identified involved those
used for stopping premature labor, treating genital herpes,
tranquilizers, new generation antibiotics, treating
condyloma acuminata and oral contraceptives. Another type
of drug usage change involved using different combinations
of new and existing drugs. Brief discussions about drug
usage during this part of the interview indicated that this
is an area of practice that changes rapidly and one in which
the physicians' own experiences are influential in
determining their use of a drug. For instance, several
physicians described situations where they went back to
using a previously prescribed drug because the new one
produced too many harmful side effects or it turned out to
be less effective than predicted.

Many drug changes, like the new antibiotics, are not
conceptually new methods of treatment but simply new
generations of-existing drugs. The gradual evolutionary
nature of these types of changes seemed to make it easier to
incorporate them into practice.

W This area of
practice had one of the lowest number of changes. Most
physicians indicated that once they had set up their
practice and mode of operation they have not changed. Some
changes that were identified included giving patients more

handouts and using some audio-visual aids. Interestingly,

114
the medical-legal climate has stimulated some changes. For
instance Dr. 105 states:

I think we've become much more careful about
documentation, information that we give them--we try to
be as informative as possible about procedures and
about risks, because of the medical-legal climate.
We're much more sensitive to the medical—legal climate
today, which was something that wasn't there 20 years
ago. Documenting everything in the chart, even to the
point of having patients sign, sometimes, the fact that
you told them something.

Dr. 106 echoed this concern by saying:

Because of the problem of being sued, we are now

having patients sign informed consents for many of the

procedures which we do. This shows that they have been
told about the procedure.

W The purpose of this
change type classification is to identify new equipment,
techniques or tests used in the diagnostic process. The
most common type of changes were in the use of ultrasound,
office D and C's, hysteroscope, performing routine blood
sugars on obstetric patients, measuring height of fundus for
identifying growth problems, use of laser treatment, and
measuring fetal lung maturity. The surgical subspecialist
obstetrician/gynecologist interviewed had the greatest
number of changes in this area, some of which included new
absorbable long retention sutures, soft tissue clamps,
retractors and suction catheters. Overall, the general
obstetrician/gynecologist does not use many tools and tests.

DiagnosisIApprgagh. This change type classification
was difficult for most physicians to respond to in that it

required looking at an overall approach to identifying a

115
medical problem rather than a specific act or treatment.
Also, because some of the change types are not mutually
exclusive, there were changes mentioned involving other
change types that might also fit here. For instance, a new
test which would be considered a technical change might also
play a key role in changing the way a physician approaches a
diagnosis. Some of the changes mentioned included screening
all pregnant patients for diabetes, routinely checking blood
work measurements (MCV's), becoming more conscious of
nutrition and using gonadotropins for diagnosing ectopic
pregnancies.

mm. This change type
classification involves changes in techniques, tests or
tools that are used to manage a patient's condition once the
diagnosis has been made. These changes include longer
retention of superpubic catheters, use of Rhogam before
delivery in Rh negative women, use of prostaglandins to
bring on labor, increased use of fetal monitoring in labor,
fasting blood glucose test rather than glucose load test,
more aggressive suctioning of meconium, different surgical
approaches, using a birthing room and allowing obstetrical
nurses to have a much broader opportunity to intervene.

Some changes in this change type classification are due to
the change in technical diagnostic procedures previously
described.

Management_Apprgach. The relatively few changes

identified in this change type classification parallels that

116

of the diagnosis approach classification. The basic ways in
which medical conditions are handled, or protocols, do not
change at the same rate as, for instance, drug usage.
Changes in these areas require much larger conceptual
innovations which are not as common. Some examples
mentioned included being more aggressive in dealing with
growth retardation during pregnancy, no longer using
pre-operative radiation therapy in the management of
endometrial cancer, trying to treat subclinical viral
lesions of the genital tract, less radical excisions for
vulval carcinoma, fewer drugs used, increased use of
caesarean section in breech presentations, inducing all
gestational diabetics, vaginal deliveries after a first
caesarean section, and trying to help patients to be more
responsible for their own health.

an_£dugatign. Physicians identified the least number
of changes in this change type classification. All but one
physician stated they had made no changes within the last
two years in the way in which they approach their own
education. Most physicians indicated that once they set up
practice and established habits, they had not changed. One
physician did begin studying microsurgery at a dog lab which
prepared him for using the microscope in surgery. This was
a different way of acquiring knowledge for him.

Also, during this portion of the interview, physicians
were asked to identify all their sources of information.

Journals and meetings were the most consistently cited

117
sources. At least one of the physicians interviewed
belonged to a journal club where colleagues gather to
discuss some of the latest developments in the literature.
Meetings included national, state and local professional
organizations, continuing medical education programs and
hospital meetings. Other sources included audio tapes,
courses, textbooks, local peers and medical experts.
Several physicians stated that teaching medical students and
residents served as a source of information mainly because
they have to prepare talks which makes them read the
literature. Some physicians expressed a need to keep up on
the literature just to keep ahead of the residents. In
several cases, physicians learned of new drugs or procedures
from the residents at the hospitals and made changes in
their practices as a result.

Keeping up with the literature seemed to be a constant
battle and a source of some anxiety. Many physicians often
had a stack of journals, reprint articles and various other
materials sitting on the edge of their desk waiting to be
reviewed. Often physicians expressed in despair that they
were behind in their reading. Dr. 103 did state that he set
aside a time every day to read his journals.

Dr. 107 had a unique way of getting himself to do his
reading and at the same time focus on what authorities in
his specialty felt were important. Each year Dr. 107 takes
the obstetrics/gynecology residency exam. This more or less

shocks him into reading for the next several months in areas

118
where he feels he is lacking.

When physicians were initially asked about their
information sources, they did not mention their own
experiences; however, as the interviewing progressed this
source of information became increasingly apparent.
Physicians' own experiences must be viewed differently than
other information sources. Their experiences are not a
result of a designed experimental study but an accumulation
of evidence based on trial and error. There are differing
degrees to which physicians like being on the “cutting edge"
in their practice. Physicians close to the edge use more of
their own experiences and seek the latest experiences of
their colleagues and the journal articles citing clinical
trials. Other physicians may feel less comfortable working
in untested areas and prefer to wait until an authority
sanctions a particular practice or wait until there is a
large volume of supporting evidence. Here it can be seen
that the difference in physicians' approach to their
practices also-influences the way they seek information and
learn.

Local authorities or area experts are also a very
important source of information for most physicians. These
physicians are either subspecialists whose area of expertise
is highly focused or general obstetrician/gynecologists who
happen to take a particular interest in one aspect of the
practice and become an authority. Dr. 104 is an example of

a physician who over the past 30 years in practice has been

119

an area expert on several topics. Dr. 104 describes a

diffusion of information pattern which typically occurs. It
can be described as an inverted pyramid model.

...usually one man will get interested in
something and goes off and studies it. He becomes
adept in the new procedure and then comes back and
starts teaching the residents...other guys get
interested and he may give a lecture or two. Some of
the procedures we've monitored as the other doctors
start doing it to make sure they know how to do it and
that sort of thing.

Dr. 104 also provided an anecdote which shows a lighter
side to making changes in practice, acquiring new
information and disseminating medical knowledge.

...by mistake they gave me a suture that normally
the heart surgeons use on heart valves, and I looked at
it and looked at the needles attached to it, and I
thought, “Gee, this would be really great for this
procedure," so I said, “Don't throw it away--I'll use
it." It has a suture on both ends, which made it real
handy--we didn't have to be rethreading or working an
area--if you drop a needle, you could really lose it
forever.

So I started using it and I had to write a letter
to (physician), who is one of the leaders in the field
in California, and said I came across a suture by error
and you ought to try it, and now he tries it and he
goes all over the country--meetings all over the
country--he's always on the program--and now that's his
suture.

...it's the one I found here by mistake! That's
how medical knowledge gets diffused.

-‘ ‘f
O

The focus of the interview's second component shifted
between the first and the last interviews. The initial
conversations and questions centered on the sequencing of
events and learning activities associated with each change.

This general research category was investigated throughout

120
all the interviews but as basic patterns emerged, more
attention was given to why certain learning activities were
pursued. It is from this second research category that the
initial portion of component three developed.

The number of changes discussed in this portion of the
interview ranged from one to five per physician. Most
interviews included either two or three changes. The total
number of changes for all eight obstetrics/gynecology
interviews using this first component format totaled 21.
Most changes discussed had been made between one and two
years prior to the interview. The most recent change was
initiated eight months before the interview. Several
changes had been initiated more than two years ago but minor
alterations had since been made. New drugs and "tools of
the trade" were most commonly discussed rather than
diagnostic or management approachs. It would seem this is
because the former were more commonly cited as changes made
in practice and because they seemed to present the least
recall problems. Drugs, for instance, often have release
dates that help mark time and thus provide a frame of
reference for the physician.

Most obstetrician/gynecologists were either satisfied
or less than satisfied with how they were handling a
particular condition prior to their knowledge of an
innovation or change. This evaluation was made relative to
their level of satisfaction of all the other activities in

their practices. One physician was pleased with the

121
conventional method of treatment and had few problems with
it but changed when a new drug treatment was available and
was demonstrated to be superior. When physicians were asked
if first learning of a change was a result of actively
seeking the solution to a problem or routine keeping
informed and up-to-date practice, all physicians cited the
latter. Several physicians stated at this time that they
did not consider themselves innovators or particularly like
change in their lives. These physicians preferred to wait
until a change was well established and leave the risk and
experimenting to someone else.

Most physicians first learned of an innovation or
potential change through journals, colleagues, meetings or
company representatives. The information source from
journals is primarily from articles, not from
advertisements. Interestingly, company representatives
were mentioned several times as first sources of
information; however, they were not listed during the first
component by any of the physicians as sources of
information. In fact, several physicians mentioned that
although there were a few good company representatives, by
and large they were not trusted to give accurate and
nonbiased information.

Most physicians indicated that the decision to change
was based on the change being a better way of handling a
particular situation. Specifically, issues like cost to the

patient, patient compliance, large volume of convincing

122
evidence in journals and fewer complications were major
factors in change decisions. Several physicians stated that
they made the change because authorities such as the
American College of Obstetrics and Gynecology had endorsed
the change and they simply conformed to avoid possible
lawsuits. One physician made a change in his practice based
on desires of his patients.

The period of time between the decision to adopt and
the actual implementation of a change varied from days to
months, depending on the nature of the change. This time
usually included few additional learning activities. One
physician stated that before implementation he continued to
read the journals to learn more specifics about the change.
Two other learning activities included talking with a
partner and identifying the materials needed in a surgical
supply catalog.

Following implementation of a change, most physicians
continued learning about the change by reading journals,
talking with colleagues and noting their own experiences
with the change. Continued learning activities associated
with specific changes essentially became part of the
physicians' keeping current practices where the physician
simply keeps an eye out for any new developments in his or
her current practice.

The following three examples of changes and associated
learning activities illustrates the range of activities

identified within the obstetrics/gynecology study group.

123

Example41, This is the simplest and least involved
type of change observed. Dr. 102 routinely orders blood
tests for all his pregnant patients. When the blood work is
done at the hospital, many tests are performed. Some of
these tests are of interest to Dr. 102 and some are not but
are done as part of the package of tests. One such routine
test which is not specifically ordered by Dr. 102 is the
Mean Corpuscular Volume (MCV). This test is a measure of
the body's ability to produce hemoglobin. A low test value
indicates a condition known as hemoglobinopathy, a
relatively uncommon abnormality. If this test were positive
for a patient, further tests would need to be performed to
identify specifically what was causing the condition.

As of late August, Dr. 102 did not consider this lab
value in assessing the health of his patients. This test
was relatively new and had not yet been incorporated into
Dr. 102's routine. At this time, Dr.102 attended a local
continuing medical education (CME) program which included
some discussion about this test. Dr. 102 stated that when
he heard the speaker mention that physicians could be liable
if they did not pick up a patient with hemoglobinopathy
after receiving a lab report with a positive result, he
decided to immediately start considering this test result.
Once identifing the lab value ranges and protocol from the
CME program, Dr. 102 did not pursue any further information
about the test or its related condition.

Bxamplgxz. This example of a drug usage change is

124

typical of the majority of drug changes where the change
does not represent a new conceptual idea or methodology.
Many of the changes physicians encounter are of this nature.

Dr. 103 is an obstetrics/gynecology oncologic surgeon
who one year ago adopted a new generation antibiotic,
Cefobid, for prophylatically treating his surgical patients.
Most surgery Dr. 103 performs involves the genital tract
which becomes easily infected. Prior to surgery three to
four doses of a broad spectrum antibiotic are given to
establish a tissue level of antibiotic appropriate for the
anticipated organisms. Cefobid is the latest in this series
of antibiotics. Dr. 103 first learned of the new drug in
mid-1983, first from reading journals and then by drug
company representatives. Other sources of information
included Drug Bibliography, clinical trials and reports of
clinical studies.

We principally hear it from the pharmaceutical
houses' representatives who come and present the data
about the drug and give us reprint articles, all of
which strangely are in favor of the drug!

Well, we looked at the cost--I guess that's the
thing that really influenced us. Since it's really a
twice a day dosage, it really wasn't any more expensive
than the three or four times a day dosage of some of
the alternatives or the prior generation of category of
drugs. So we said, "Why not just try the new one?"
It's only twice a day—-expense is the same. The
bacterial spectrum looks better, on paper at least, and
so in a matter of just two or three weeks of checking

that out with the pharmacist to be sure that the cost
is comparable...

Dr. 103 has continued learning about the use of Cefobid

by reading articles in journals when they appear and

125
reviewing literature that drug company representatives
provide.

Example_3, Dr. 107's change in becoming more
aggressive in suctioning of meconium from the fetus at
delivery represents a change in the category of technical
aspect of management.

We've always been concerned about meconium in the
past and felt that it may reflect fetal distress, and
it may or may not do that, but we have learned that if
the fetus at delivery does inhale the meconium into his
lungs, it can cause a terrible pneumonitis, and so we
have become more aggressive with visualizing the vocal
cords and suctioning that even down below the vocal
cords, which was never done before the last couple
years.

Dr. 107 was unclear whether he first learned about this
suctioning of meconium at a hospital or department meeting
where clinical problems are discussed or from reading
journals. He thought that perhaps he received information
from these two sources at about the same time. Dr. 107
immediately became more sensitive to this procedure and soon
attended a special seminar to improve his skills performing
suctioning. The seminar was taught by a perinatologist from
one of the local acute care hOSpitals. Local obstetricians
were instructed about neonatal resuscitation, the management
of newborns and complications. During the seminar the
obstetricians used anesthetized kittens to practice
visualizing the cords and suctioning. Dr. 107 found the

experience very useful and amazingly similar to intubating

humans, except for the kittens' sharp little teeth.

126

The first two components focused on how changes and
associated learning behaviors take place. The parameters
outlined by the three examples illustrates the scope or
degree of variation which loosely defines the relationship
between making changes in practice and associated learning
behaviors. As this area became repetitive, that is, reached
saturation, the question of why physicians pursue learning
not directly associated with changes in practice, what type
of learners they are and how they go about learning, became
important. Some of these concerns were identified during
the earlier interviews and stimulated the development of the
third research component. It became apparent that the way a
physician learns in response to a change is dependent on the
type of learner he or she is. A physician's innovativeness,
willingness to learn and ability to make changes are all
interrelated and highly dependent on the nature of the
individual physician as a learner. This component was
initially introduced in a simple form during the last
obstetrics/gynecology interview and expanded with the
beginning of the internist interviews.

The last obstetrics/gynecology interview initially
followed a similar course as the previous interviews. Dr.
109 outlined the various changes made and described one
change in detail. The third component began by Dr. 109
responding to a question about what motivates him to pursue

one of the many things like journal articles that he

127
routinely encounters. Dr. 109's response was, 'Pertinence
to practice. How germane is it to my personal practice.“
Dr. 109 then picked up a stack of journals to be read and
reviewed the table of contents.

"Outcome and Effect of Medical Intervention in
Women Experiencing Infertility Following Removal of an
Ectopic Pregnancy.“ That's something that's germane to
my practice. "The Role of a Swan-Ganz Catheterization
in Severe Pregnancy Induced Hypertension.“ Well, I
know that's something to think about, but I'm probably
not going to read the article.

I've never put in a Swan-Ganz catheter in my
entire existence, but a case was presented recently
from another physician right next door, in fact, in
which a Swan-Ganz catheter was strongly recommended.
Well, the thing is, now at least I have a perception of
under what set of circumstances a Swan-Ganz catheter
might be of value. I don't have to read this article
now. But at least I can say, “Hey, that patient is
experiencing these kinds of things, and I think I'm
going to ask (physician) to come over and see my
patient to see if this patient might benefit from the
Swan-Ganz catheter. And so prior to either this
article, if I had chosen to read it, or prior to the
presentation of that particular case, which I had never
seen before, I would not have even thought of using the
Swan-Ganz catheter.

Continuing in this same direction, Dr. 109 was then
asked how, when confronted with many articles or lectures
that are germane to his practice, does he decide to pursue
one rather than another. Dr. 109's response was that his
choice is based on his perception of personal deficiencies.

Dr. 109 also identified a special learning need which
subspecialists like himself have. To maintain their status
as a “super authority” in a specific area they must improve
already good knowledge so that it is superior to others in
the local community. Subspecialists must be at least better

informed than the person who just read the latest review

128

article.

The last part of this interview centered on looking at
Dr. 109's total learning activities, not just the medical
aspect, but all areas of of his life. Dr. 109 prioritized
the major areas of learning in his life. By far the
greatest time and energy spent on learning was with his
medical practice. A distant second area was with a
nonmedical related hobby. Areas three and four were
associated with medical administration and medical
societies.

The last question asked was, 'Do you set aside a time
for learning?” Dr. 109 said that he set aside the time from
5:00 until he falls asleep after the office closes. This
involves approximately one to one and one half hours, four
days a week. This amount of time is sufficient to allow him
to pursue areas of interest if he picks and chooses what he
looks at. Again, those things that he usually chooses are

related to areas he perceives as his weaknesses.

I! I I J H 3' . I I .

A common change pattern with associated learning
activities was identified as a result of the
obstetrics/gynecology interviews. This behavior pattern
typifies physicians as being in a general state of alertness
for information which is relevant to their practice. Here
the term ”relative to their practice" includes anything that

improves a way of solving a particular medical problem, is

129
more convenient for the patient or physician, reduces the
medical-legal problem, helps the physician's business become
more viable and competitive, and makes physicians secure in
knowing that they are using the best available methods of
treatment. What is relative to practice can also be
considered motivational.

For the most part, physicians structure their busy
lives in such a way that they establish a communication
network. Physicians read the literature, exchange
information with colleagues, use resource people such as
drug company representatives and pharmacists, and attend
meetings. Additionally, physicians use, to varying degrees,
their own experiences as sources of information.

Once confronted with information associated with a
particular change, the learning behaviors that follow depend
largely on factors such as how strongly the “authorities"
endorse this change, the volume of literature associated
with the change, usefulness to practice, and the cost versus
benefit consideration. Learning activities associated with
changes made in practice vary considerably. In an instance
where there is a strong motivation to change such as a
medical-legal problem, few if any learning activities may
follow the initial exposure. Other changes may require
additional information-seeking about the subject or about
how to implement the change. This latter learning behavior
seems to be directly proportional to the degree of

uncertainty or complexity of a change.

130

The establishment of an information network provides
the physician a mechanism for incorporating learning and
changes into the routine of practice. These clinically
based physicians are for the most part reactive rather than
proactive learners. The routinization of learning keeps the
physician at a comfortable distance from the cutting edge.
Physicians do not have the time or energy to pursue learning
activities in every area of their practice. They must rely
on their information network to keep them adequately
informed and up-to-date.

It is with this perspective that the study was
continued with the second study group, the internists. The
objective of the study from this point was to describe
properties of the general research categories identified in
the obstetrics/gynecology specialty group, to expand the
parameters of the categories and to identify instances that
did not conform to or fit the categories.

Of the 20 internists initially contacted by a letter of
invitation, five responded positively. The remainder of the
study subjects were recruited by personal invitation. Most
physicians were very reluctant to take the time to
participate in the research project. Response rate was much

better when physicians were personally asked by a colleague.

I] I I J H i' . E El . .
The interview with the internal medicine resource

physician, like that of the obstetrics/gynecology resource,

131
yielded information about the specialty from an individual
practicing within the specialty but at the same time removed
somewhat by activities in medical education. After
discussing some preliminary findings from the
obstetrics/gynecology interviews, two areas of interest were
discussed. The general conversation is as follows:

The distribution of health care provided by
physicians in private practice, as in this town,
differs considerably from the type of medicine
practiced in a university research community. The
purpose of a private practice system is to distribute
the best care possible, with what resources are
available to the greatest number of people. Research
oriented health care, on the other hand, focuses large
amounts of resources on relatively few patients. It
would not be possible to provide this kind of care on a
large scale. So, because of limited resources there is
an inverse relationship between the quality of care an
individual receives and the quality of care for
everyone in a community.

Internal medicine as a specialty is primarily
involved in treating disease processes. Internists are
best known for being good diagnosticians. Diseases are
treated with drugs, diet and exercise. Internists are
generally not involved in surgery, childbirth, the
reproductive system or mental illness.

Internists can be grouped into three different
categories: general internists, subspecialists who
also practice general internal medicine and those
subspecialists who have basically a consultative
practice. The third group relies heavily on referals
from other local physicians.

I I J H i' . I I . --F' I E I
Physicians were asked to identify changes made in
practice based on the eight change type classifications. To
establish a base of understanding of the specialty, more
time was spent on this component during the first several
interviews. Less effort and time was spent on the first

component during subsequent interviews so that more time

132
could be devoted to the third research component. During
the final interviews, there was only the briefest
investigating in this area, just enough to identify several
changes that could be examined in more detail in the second
research component.

The distribution of changes identified within each
change type classification paralleled those observed in the
obstetrics/gynecology specialty group. The greatest number
of changes were seen in drug usage which is not surprising
considering the nature of the specialty. The following is a
brief outline of the changes identified in each of the eight
change type classifications and related significant
observations.

WW Most of the
internists interviewed practiced in large group practices
with as many as nine physicians in the group. Because of
the size of the practices, many physicians were able to make
large, expensive changes in this change type. Office
computerization, principally for billing purposes, was the
most commonly cited change. Other changes included adding
new partners, revising an employee manual, and starting a
routine of evaluating office staff twice a year.

One physician was relatively new in practice and had
experienced a marked increase in patient load within the
last two years. At the start of Dr. 115's practice, most
patients were new and required an hour-long physical exam.

This was time consuming; he was able to see only a few

133
patients per day. More recently, Dr. 115 is seeing those
same patients for 15 minute office calls which has increased
his patient load. This also changes the way Dr. 115
practices because he is increasingly seeing patients who are
coming to him for specific problems rather than routine
health care.

Dr. 114 has also experienced an administration/office
procedure change which has altered his basic mode of
practice. Recently, Dr. 114 and several other physicians
changed their practice from being hospital-based to a
private corporation. This has required Dr. 114 to take on
more administrative responsibility, become more specialized
in his practice, more dependent on his partners and changed
the focus of his practice from a patient to a service and
hospital-based consultant focus. This also changed the way
in which Dr. 114 relates to the people he serves.

Drug.flsg. Changes in this change type classification
fell within five general areas: anti-anginal and
hypertension, anti-inflammatory, newer antibiotics,
antidiabetic agents, and arthritic medications. Within each
of these areas there are many individual, but closely
related, new drugs.

Dr. 111, a subspecialist, said that a large part of his
drug usage changes involved new protocols for existing
drugs, not new uses, but new ways of using them for the same

conditions.

Patisnt_Bslatignship_and_fldusatign. Educating patients

134
about procedures and health care following acute medical
conditions such as heart attacks was an important part of
practice and an area where physicians had made recent
changes. Speaking to this subject, Dr. 113 said, 'I think
patients demand it now." Several physicians stated that
they have made an effort to train or hire nurses who can

provide much of the patient education.

Several topics were discussed in association with this
change type classification that were only tangentally
related but revealing.

Dr. 111 has become increasingly cost conscious when
dealing with patients. This interest in cost containment is
in response to a national crisis in rising medical cost.
According to Dr. 111, what motivates physicians to be

concerned about cost is local peer pressure.

... we also have very strict review committees set
up in the hospitals that look at what you do and peOple
who are on those committees will come and speak to you

directly...
Physicians in general are concerned about policing cost
because they feel if they don't, it will be imposed on them
by government or third party payers, which in many instances
is already occurring. This pressure requires the physician
to stay on top of things and is one reason for information
being communicated.

Dr. 115 has recently changed the way he relates to his
patients by trying to tailor his educational efforts to the

individual patient. “The same approach can't be used on

135

everyone." Also, with patients who have multiple areas of
concern, such as smoking, excess weight, and poor diet, Dr.
115 has learned to prioritize what he wants the patient to
do and try to accomplish in stages over a long period of
time, rather than hitting the patient all at once.

Dr. 120's change speaks best for itself in his own
words.

I have made my patients more responsible for their
own care. That is, I don't feel as responsible for
them as I once did. This was a real turning point in
my practice. I was going crazy with worry about them
before I started verbalizing agreements with them and
asking if they had questions and helping them to

understand their condition. We basically enter a
partnership. Like a contract.

Igghnigal_Aspggt_gf_Diagngsis. The most commonly cited
”tool of the trade" type of changes included the use of
echocardiagraphy, nuclear cardiology, nuclear radiology, CAT
scans, flexible sigmoidoscope, and in-office glucose testing
and pulmonary functions test. Most of the changes in this
area involved the use of sophisticated equipment or
techniques that are performed by subspecialists or
technicians in the local hospitals.

Dr. 111 cited one technical change, the nuclear
magnetic resonator (NMR), that has not yet reached this area
but is an innovation he has been learning about in
anticipation of someday making its use a part of his
practice. Dr. 111 first learned of the NMR two years ago
from the journals. Since then, there have been two local

conferences where visitors from centers that have NMRs have

136
given presentations.

Diagnostic_Apprga§h. Some of the changes made in this
change type classification, not associated with those
related to changes in technical aspect of diagnosis include
increasing the number of stool specimens ordered per year
for detecting hidden bleeding, more mammography, more
thyroid function tests, and looking for more neuropathy
signs in diabetic patients.

Dr. 115, one of the younger physicians interviewed,
stated he has become increasingly sensitive about
considering all variables concerning a patient including
age, activity, life style and habits when making a
diagnosis, not just the particular signs and symptoms
presented by the patient.

Iechnigal.Aspegt_gf_Managemgnt. Several technical
changes identified which have changed the management of a
condition include new tests for measuring drug
concentrations, use of ultraviolet light in peritoneal
dialysis to decrease the spread of bacteria, and more
sophisticated pacemakers.

Management_Apprgach. Those changes in management
approach identified which were not related to a technical
aspect were more aggressive use of steroids in higher
dosages for glomerulonephritis, increased emphasis on home
blood glucose and blood pressure measuring, and use of more
potassium-sparing diuretics.

QWn_Edug§tign. Only one internist cited a change in

137
this change type classification. Dr. 115 is a relatively
young physician whose interest in the literature has shifted
from basic research, which he was most interested in during
his residency and before his Boards, to clinically oriented
articles. He has also shown more of a preference recently
for review articles.

The next portion of this change type classification,
like the obstetrics/gynecology study group interviews,
focused on the various information sources used by the
physicians. More emphasis was given to why sources of
information were used, under what circumstances, and how
physicians manage the information they obtain.

The most commonly cited sources of information were
journals, colleagues, meetings and textbooks. For the most
part, the information sources used by the two specialty
groups were very similar. Several physicians mentioned
throwaway publications as information sources but were
skeptical of them because of their affiliation with
profit-oriented businesses. Reading journals was the most
important source of information. Physicians benefit from
their reading by identifying new things they can use in
their practice, reviewing what is happening in basic
research, identifying what is going to be available in the
future, and reinforcing what they already know.

There are several ways in which physicians manage their
journal reading. Most physicians routinely review their

journals on a daily or weekly basis and have developed some

138
kind of system to save the information that is relevant to
their practice. Most physicians create their own resource
library. Physicians keep these libraries in their homes or
offices. The particular system used varies from simply
saving the whole journal, to cutting and filing in an
indexed, cross-referenced storage system. Dr. 120, for
instance, likes the journals with the advertisements in the
front and back of the journal so he can tear out all the
pages with advertisements, review the articles and file the
remaining portion of the journal.

These information storage systems are highly
personalized and in a sense are both a security system and
an extension of the physicians' internal data base. Dr.
114, for instance, has a rather extensive information
storage system. This subspecialist collects articles
related to his subspecialty and review articles in general
medicine. Dr. 114 tries to ”skim" these articles or review
the abstracts before filing them. Even if he doesn't read
them at all, he at least has a visual image of the article
and knows it is there if he needs it.

Physicians use their resource libraries to find
information concerning a particular case, prepare for a
presentation they are going to give as part of their
volunteer teaching responsibilities, prepare for journal
club, and prepare for hospital section meetings.

Dr. 112 has been questioning his information

acquisition and storage system in light of advances in

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computer usage.

I'd say in the last couple of years the articles
have tended to be pulled and stacked and haven't gotten
into the files, and I'm tending to do that less and
less with the advent of computer searches, because it's
far easier and two of the drug companies will do it for
us in (subspecialty). I'm sure that's true of others.
We can call a number and they will give us a computer
printout. They do the same thing at the libraries, but
the library would cost the hospital. The drug
companies will do it for you for free, and I think they
probably even have a bigger source of computer--bigger
computer source, so I tend to do that. I've found my
files are obsolete. I'm really beginning to think--and
maybe this is an excuse--but I'm beginning to think
that it's a frustrating effort to try to keep one's own
files. I just don't think that's--in today's world of
computers, that's not a very practical thing to do.
Learning from colleagues is an important part of

physicians' information acquisition system. Colleagues can
include residents, group partners, local attending
physicians, subspecialists, and physicians in research
centers. Most of the information obtained from colleagues
is case related. Physicians consult with their peers when
they have a difficult case, need additional information, or
just would like to confirm that what they are doing is
acceptable. Younger physicians rely more on older
established physicians. Some physicians in large practices
find colleague consultation particularly convenient because
they often have a good resource within their own office. In
fact, in some group practices, each physician is a resource
for a particular area of practice and keeps everyone
up-to-date in that area. Subspecialists whose main area is
rather narrowed but who still practice some general medicine

often find residents useful sources of information. Because

140
residents are preparing for Board exams and have a broader
exposure, they are often very knowledgeable in areas where
subspecialists have little contact.

Dr. 113 is a subspecialist whose business primarily
consists of referrals from other physicians and
consultations. As part of his role as an area expert, Dr.
113 disseminates information to other physicians such as
general practitioners and internists who are not involved in
his subspeciality. When providing consulting services, the
other physicians must have some knowledge of certain
protocols in order to facilitate Dr. 113's efforts. This is
information that Dr. 113 forwards to his colleagues.

Of course, we usually have letters telling them
about a new drug and telling then why we do certain
things (like you need certain blood counts, check this,
and particularly like some of the patients come down
from the smaller cities) so I usually send them a
letter saying I suggest using this drug and please get
a CBC, BUN, or something like that.

Dr. 114 identified yet another colleague information
acquisition method. Dr.ll4 is a consultant for a
bio-medical company which pays a stipend to send him to
special conferences several times a year. At these
conferences, 40 to 45 other consultants from all over the
country exchange information with each other and company
representatives. Here Dr. 114 has an opportunity to speak
directly with researchers and other clinicians.

Several physicians expressed mixed feelings about

physicians who practice academic medicine. On the one hand,

private practice physicians rely on academic physicians for

141
developing and promoting changes in medicine and for
information resources. On the other hand, private practice
physicians feel that the ”ivory tower" physicians are too
far removed from ”the real world", practice in an ideal
environment, and often expect private practice physicians to
do things that are not feasible. Dr. 118's comments were
particularly interesting in light of this observation.

Dr. 118 is a subspecialist who ”markets" himself as a
consultant in a highly specialized area of practice. Dr.
118 had been practicing at a university hospital and moved
into private practice within the last two years. When
questioned about his learning relationships with other
physicians, he indicated a disappointment in private
practice physicians' motivations when it comes to learning.
He believes that economic incentives are a dominant
influencing factor in their behavior and thought this to be
so to the point of interferring with the transfer of
information from one physician to another.

Learning from meetings includes a broad range of
activities from local hospital to national meetings. Local
hospital meetings seem to be viewed differently depending on
the degree of specialization. General internists who often
rely on their peers and subspecialists in the community to
learn new things, find the meetings are valuable
experiences. Subspecialists who have a very narrowly
focused practice find some of the meetings less beneficial.

National meetings offer more opportunities for all

142
physicians to find useful learning opportunities.

Dr. 112's comments focus on another useful benefit of
attending meetings.

... you're stimulated again to be thinking in a
logical and precise fashion, where I think if you see
patients and get in a rut, doing a routine every day,
you tend to get a little leppy in your thinking. So I
think it hones your thinking process. So, you know,
when I talk to the residents and tell them what I think
the advantage of going to meetings are, those are the
kinds of things I try to emphasize, rather than you're
going to come away with a cure for something, cause if
that's what you go to a meeting for, I think you're
disappointed.

One of Dr. 111's information acquisition methods is
closely tied with the technical aspect of management
category. Dr. 111's method of treatment for his patients
with malignancies is in a constant state of evolution. The
protocol for treating specific conditions is constantly
changing, based on experiences with the treatment methods.
Dr. 111 belongs to a nationwide organization that collects
data from physicians all over the country and provides
participating physicians with a bimonthly update on how well
a particular protocol is doing. In addition, physicians
have telephone access for even more up-to-date information.
Dr. 111's own experiences with a particular protocol alone
would, at best, be anecdotal and give him little ability to
make decisions based on the merits of a particular
treatment. By contributing his data to a larger information
system, Dr. 111 can watch the research develop as all the

data come in and then be provided with what he considers to

be the most up-to-date treatment available to the private

143
practice physician. Furthermore, this organization sponsors
meetings in which participating physicians can on a more
personal level discuss the protocols.
... I have not personally attended. I have not
been brazen enough--I'm getting to that stage where I'd
feel comfortable to stand up in front of the smartest
people in the world, as far as I'm concerned, in this
field, and voice my opinions. Yes, they have meetings
where this committee that's in change of this protocol
meets and where I'm welcome to attend. No, I've not
personally attended those sessions to date. Partly
it's a matter of time and partly it's my bowing to the
”greater gods" in (subspecialty).
Dr. 111 also commented that when he has a question in a
familiar area, he simply looks in the Index Medicus for the
latest articles by those authors he considers to be

authorities.

I I J H i' . I I . __5 i E I

The way internists go about making changes paralleled,
for the most part, obstetrician/gynecologists. There were
no contradictory findings between the two groups although
properties of research categories differed in degree. Some
areas of study-were expanded but did not negate previous
findings.

In summary, most internists were well aware of changes
in their own areas prior to the availability of an
innovation. Research articles in journals were by far the
greatest sources of first information. Further information
was obtained from meetings and colleagues. Once the change
was made available, physicians usually adopted rather

quickly. Few physicians used advertisements or company

144
representatives for information sources or decision making.
Several physicians stated that they did not see company
representatives or even let them in their office. Following
implementation, physicians evaluate the practice based on
their own experiences with the innovation and wait for
updating information from review articles or toxicity
reports. These sources of information come either from
journals, reports at meetings, or local colleagues.

One factor that greatly influences change behavior and
learning patterns is that most internists studied are either
subspecialists or general internists who have narrowed their
practice to a limited area such as diabetes. Other patient
problems are more often referred to a subspecialist or the
physician uses the consultation services of another
physician. This allows the physician to concentrate on
being better informed in at least one area.

The internists did differ from the
obstetrician/gynecologists in two areas. First, the
medical—legal concern, although definitely noticeable, was
not as acute a problem for the internists. Second, there is
no strong nationwide organization that officially sanctions
certain practices. As a result, some physicians enjoy a
sense of freedom from being controlled while others would
feel more secure having someone else determine standards of
practice, thus relieving them of some of the responsibility
and decision making of their practice.

In a sense, standards of practice or acceptable

145
practices are being determined by government, Medicare,
third party payers (insurance companies), health maintenance
organizations (BMOs), and industry. The organizations have
an influence on what will be paid for any given treatment or
procedure. If the physician charges more than what has been
established or deviates from standard practices, it is the
patient who then must pay the difference. This creates a
physician-patient problem for the physician as most patients
can not, on their own, afford expensive medical treatment.
Dr. 120 expanded on this issue in his conversation about
controls being externally imposed on the medical profession
in an effort to solve the cost containment problem. His
response to the question, "Do you feel that there are
abuses, unnecessary procedures done by physicians?" was:
Certainly. It is a struggle that all of us must
contend with. The problem is that patients do not
appreciate the cognitive type of things we do and don't
want to pay for them. They don't see the thought work
that goes into an hour office call, the phone call to a
colleague, the reading, etc. They think 75 bucks for
what? But do a procedure that costs the same and they
don't mind paying. Usually the third party picks up
the cost so they don't really care. Since many
physicians feel that they cannot charge what they feel
they are really worth, they decide to make their money
from procedures.
The following examples further illustrate internists'
practice behavior.
Dr. 114 is a subspecialist in a group practice where
each partner has specific areas of expertise and is

responsible for keeping the others in the practice

up-to-date in his area. This group systematically develops

146

standard protocols for certain aspects of their practice
which are then compared to state and national results.
Based on a comparison of data and evidence in the
literature, the group made a decision to switch to a new
drug. This change will take place as soon as the drug
becomes available. Dr. 114's relationship with his partners
is more structured and involved than other groups of
internists, his adoption pattern for this particular change
is highly quantifiable compared to other physicians' change
behavior, but his learning pattern for changes related to
his subspecialty is characteristic of his specialty group.

Dr. 120 very succinctly illustrated some points he had
been making throughout the interview by describing his
motivation for making two changes in his practice:
increasing examination of diabetic patients for neuropathy
signs and better foot examination, and doing more pulmonary
functions tests during routine physical examinations of his
patients who smoke.

About 50% altruism and 50% fear. It should be
done to protect the patient but also I could be liable
if I failed to keep very close check on my diabetic
patients.

Well, the ivory tower (academic medicine) says
that all smokers should have this done at their annual
checkups. The other motivation is that it is a
procedure that I can make a good profit on and it

doesn't require any of my own work. We hire a
technician to do it.

I l 1‘" i' . I I . --II' 1 E |

Following the last obstetrics/gynecology interview in

147
which a preliminary third component was initiated, more
effort was given to investigating internists as learners.
The general areas of interest include why physicians are
motivated to learn and make changes, how physicians make
decisions about what to learn, how physicians learn, and
what part learning plays in the non—medical aspect of
physicians' lives.

Physicians were first asked to identify one aspect of
their practice that they were so displeased with that they
actively sought to make a change. None of the physicians
interviewed could cite such a change having been made in the
last two years. Typically, the answer to this question was
that they are unhappy or insecure about many aspects of
their practice and are always looking to improve. When a
possible improvement in practice is identified from their
readings, colleagues or meetings, they evaluate the pros and
cons and consider it for adoption. If implemented,
physicians judge the change and its continued use on their
own experiences, others' experiences, and updated
information obtained from journals and meetings.

The second question of this component concerns what
prompts physicians, when confronted with so many learning
opportunities, to select one area or topic over another.
For instance, when a physician goes to a national meeting,
why does he or she select one presentation over another?
When looking through journals, what motivates the physician

to look at one particular article? This question elicited

148
two types of responses. Most literally taken, physicians
described what stimulates them to pursue learning
activities. Further discussion revealed the more underlying
motivations for continued learning.

Most physicians are stimulated to seek learning
experiences that have direct practical application to their
practice. Physicians feel they have little time to explore
areas or topics that do not directly apply to the type of
patients they see. Generally, physicians look for very
specific, current information concerning those areas they
see most frequently. They use review articles or condensed
information in areas they have less need for but wish to be
reasonably informed. Dr. 112's description of his journal
review behavior is fairly representative of the responses
identified.

...in a general medical journal like, well, the New

England_figurnal I try to read as much as I can of that,

because I feel that gives me an opportunity to keep up
in general medicine. In the medical specialty journals
like Annals or the NW.
basically what I do there is I would just pick out
(subspecialty) stuff and read that. In the Annals if
there is something that would catch my eye as being a
real significant review article or a big advance in the
general field of internal medicine, I would tend to
either read it or pull it out and say, "I'll read it
some other time," which I've found over the years that
once I do that, that's as good as saying I'm not going
to read it.

Physicians also mentioned that they liked to pursue learning
activities involving new or revolutionary types of changes
rather than the more typical modifications or evolutions of

existing practices. Several physicians said that their

149
choice of learning activities also depends on the source of
the information. That is, credibility, experience and
degree of authority in the area of a author or lecturer were
influencing factors on a physician's decision to pursue a
learning activity. Lastly, physicians may seek information
in areas where they anticipate they will have a need, again
based on serving a specific clientele.

Some physicians were also able to identify the deeper
underlying motivations for continuing to seek new
information and make changes in their practice. Physicians
responding in this way generally cited several motivating
forces. A physicians' pride or self-respect is an important
factor. Especially in a teaching hospital situation,
physicians do not want to look like a "dummy" in front of
their colleagues. Therefore, learning activities are
important for consultations with peers, preparing
presentations for conferences and being accompanied by
residents are primary motivators. Competition and the need
to "market" themselves as a subspecialist are also important
motivations for pursuing learning. Several physicians
expressed a need to bridge a knowledge gap, investigate
things they do not feel comfortable with or relieve a
feeling of inadequacy in an area. Another motivation is to
do the best they can for their patients. Dr. 111 treats
many terminally ill patients and spoke to this point.

...it sort of provides you with a security blanket that

I'm doing the best job that anybody can do. I know as
much as anybody knows about these areas, and I can't

150

save you. In other words, how would I feel if I

thought that I knew less than--these people were dying

under my care and I thought that somebody else really
knew more than me.

Dr. 120 candidly outlined three reasons why physicians
pursue learning. First, physicians are "altruistic." The
overwhelming majority of physicians genuinely want to help
others. "Greed" is another motivating force. Physicians do
want to make a good living. Thirdly, physicians learn out
of ”fear.“ For example, physicians fear loss of their
practice, lawsuits and not being a good physician.

Next, physicians were asked about how they organized
their learning activities. Since most physicians cited
journals as their major sources of information, they were
asked if they regularly set aside a time for reading and if
that amount of time is adequate to keep up on the
literature.

Responses ranged from not designating a specific time
each day or week to being highly structured with a specific
time set aside just for reading. The amount of time spent
reading also varied. For example, some physicians said they
read 30 minutes per day after the evening newspaper, two to
three hours per week in the evenings and on their day off,
and another reported reading 15 to 30 minutes per day with
no set time.

Anxiety about not keeping up with the literature was

felt by many physicians. Comments expressing this feeling

included: "Journals just keep piling up, it's impossible.“

151
and 'It's just a matter of keeping my head above water." To
relieve this problem, physicians develop a method of
reviewing the journals and extracting the information they
desire. Many physicians said that when they go through
their journals, they read the titles and determine if the
article contains something that is relevant to their
practice. That is, do they have patients who would benefit
if they read the article or would this information improve
their practice. If the article is thought to be useful,
physicians may either read the abstract, read the last
sentence of the abstract, read the entire article, or clip
and file the article. As a result of this method,
physicians spend time reading mainly those things that are
case related, commonly seen in practice, or having direct
clinical application. Some physicians seemed more
comfortable with this picking and choosing method than
others. Several physicians who very strictly apply this
system said that they were actually able to have enough time
to explore areas of interest on occasion or to do some
non-medical reading.

The selective method of journal review is typical of
the type of prioritizing physicians must do in their
practice. For example, Dr. 119 has no partners and
practices general internal medicine. Most of his patients
are people, like diabetics, who need maintenance care, most
are not critically ill. Dr. 119 admits that he could be a

“better“ physician by reading and pursuing more learning

152
activities but has established certain other things in his
life, such as his family and church, as high priorities. He
has subsequently designed his practice within these
parameters.

Dr. 120's comments illustrate another aspect of how
physicians manipulate their lives to solve the problem of
information overload.

There really isn't anything that you can do about
slipping back, it is going to happen. In academic
medicine you have the time to read and investigate new
things, you don't have that luxury in private practice.

Physicians in academic medicine are really just
subspecialists anyway. It is much easier to be and
feel up-to-date that way. That's what usually happens
in private practice also. For instance, I have
narrowed my practice to one group. Therefore I can be
an area expert in that one area. This gives at least
some security about keeping up-to—date.

The final portion of the third component was an attempt
to identify what part of a physician's total learning
behavior medicine takes up and what other learning
activities physicians pursue. All physicians stated that by
far, medicine consumes most of their learning activities.
Learning outside of medicine includes reading and engaging
in activities such as special interests or hobbies. Aside
from reading for pleasure, for instance a novel, physicians
read to obtain information about topics such as history.
current events, philosophy, religion, personal growth,
photography, sports, and investing. Activity oriented types
of learning, like those involving hobbies, include taking

classes, sailing, tennis, church involvement, and nature

enjoyment.

CHAPTER V

CONCLUSIONS AND IMPLICATIONS

This study has resulted in a description of physicians'
practice behavior and learning activities associated with
changes made in practice. The purpose of Chapter V is to
qualify these findings with respect to the research
methodology, summarize and draw conclusions based on the
physicians' behaviors outlined in Chapter IV, and to
correlate learning associated with change to the general

patterns of a physician's practice.

MSLthQlQQX

In addition to describing physicians' practice behavior
and learning activities, this study has demonstrated that
grounded research methodology can be used to generate
meaningful and useful data. Grounded research has not
commonly been used in this area of study. Consequently,
there has been little history upon which to prove this
methodology's ability to produce theory.

This study began with a broad orienting concept which
guided the initial data collection. As data were collected,
they were coded and separated into research categories.
These categories served as a way of organizing the data

153

154

as they continued to accumulate and to compare groups of
similar data to other categories or data from another study
group. The direction of the research was in fact ever
evolving as questions and conclusions, based on previous
data, were used to guide future data collection. The
presentation of the findings in Chapter IV and the resulting
conclusions presented in this chapter substantiate the
usefulness of the grounded research methodology in this
area. The results of this study provide proof of the
research methodology's success at producing meaningful and
useful data which can be used to formulate theory. To wit,
the proof that paint, brush and canvas can be used to
produce a painting is in the painting. Thus, as a result of
this methodology's theoretical sampling, comparative
analysis and theoretical saturation techniques, sufficient
data were obtained to describe physicians' learning and
change behaviors and to formulate substantive theories, that
is, theories based on a limited empirical area. Theories
identified in a substantive area relate to that setting and
specific populations. They are not generalized from one
situation to another. Therefore, concepts related to this
study will not be extrapolated to other settings or
populations.

The findings and theory formulation resulting from this
research also attest to the usefulness of a semistructured
interview as a tool for collecting data. The semistructured

interview establishes a framework for organizing data

155
collection. At the same time it provides the necessary
flexibility needed in a grounded study. The semistructured
interview, like all other research tools, has its inherent
flaws including the inhibitors of communication, the
willingness and ability of the subjects to respond, and the
researcher's perceptual and interpretive limitations.
However, this research tool did produce large amounts of
useful data that articulate successfully with a grounded

research methodology.

Eh! . . , E I. E l .

The data from this study indicate that a physician's
practice is more than just the sum of all the many
influencing factors affecting a physician's professional
role. It is the cumulative result of each factor modifying
other factors and being modified itself. To understand any
one influencing factor's effect on a physician's practice,
that factor must be viewed in relation to the practice as a
whole. It is with this perspective that the role of
learning associated with change in a physician's practice is
viewed here.

The nature of a physician's practice appears to be
determined by a host of interrelated, interdependent
influencing factors. Among these are the physician's
abilities, psychological makeup, priorities, and
limitations. A physician's practice is also shaped by many

sociological factors such as demographic changes, technical

156
advances, the nature of clinical problems encountered, and
public pressure. Additionally, economic influences such as
the medical-legal climate, competition, and rising insurance
costs all weigh heavily on the nature of a physician's

private practice.

I I. E l . E i'

The nature of a physician's medical practice as
identified from the findings of this study, can be viewed as
the intersection of three primary determining elements.
Practices vary in the scope or extent of the medical field
which the practice encompasses, the depth of knowledge and
training within each area of practice, and by how close to
the frontier of knowledge or cutting edge the physician
practices. In a sense, the resulting practice can be seen
as an entity whose parameters are defined by a host of
influencing factors.

The scope of medical practice is influenced by a range
of factors imposed both externally and internally. A
physicians' practice is initially defined by the specialty
area. This provides a basic area in which to practice.
Further definition involves subspecialization, individual
special interest, training and skills. Those factors that
keep a practice within certain boundaries include
certifications, medical-legal considerations, peer pressure,
resource availability, need within the community,

competition, need for consults and referrals, and the

157
physician's character.

A physician's depth of practice refers to the level of
expertise within any area of medicine. Generally, the depth
and scope of practice are inversely related. Physicians who
have a small scope of practice are usually highly
specialized and serve as local authorities. Those
physicians whose practice encompasses a broader range of
medicine do not have the depth within any one specific area.
These physicians will make referrals or obtain consults more
often than those of a more narrow range. The enorminity of
the medical field, the training and skills required in any
one area, and the need to keep updated, all make it
virtually impossible for a physician to practice at a great
depth in all aspects of the practice and still maintain a
large scope.

The cutting edge in medicine can be viewed as a
constantly progressing state of understanding and practice
which is considered acceptable by authorities in specific
areas. In some instances the cutting edge is well defined;
in others there is a broader uncertainty about what is
acceptable practice. In some areas of medicine the rate of
change and progress is slow while others progress more
rapidly.

Physicians' practices were viewed as being in a
constant state of change and generally seemed to keep pace
with the movement in the medical field. Differences were

observed however, in physicians' proximity to the ever

158

progressing cutting edge. These differences appeared to be
based primarily on the physician's character or
personality--how comfortable a physician feels practicing at
the edge of knowledge. As a practice approaches the cutting
edge the personal demands and responsibilities of the
physician increase. For instance, physicians close to the
cutting edge must be more knowledgable about current
practices, rely more on their own trial and error
experiences, make more critical judgments, and take more
risks. Physicians differ in their willingness to accept
these responsibilities. Hence, the degree to which a
physician feels comfortable close to the cutting edge, to a
large extent, determines the nature of the practice.
Generally, physicians whose practice is narrow in scope are
closer to the cutting edge than those with a broader scope.

Regardless of the proximity to the cutting edge,
physicians must maintain a reasonable distance to that edge
of knowledge in order to sustain a viable practice. A major
factor forcing growth, change, and continued learning is the
medical-legal climate. If a physician were practicing below
what is considered standard practice, any problems that
might occur could lead to damaging lawsuits. Physicians are
also in competition with one another which stimulates
growth. Additionally, peer pressure is exerted, both
socially and professionally. For instance, hospital peer
review boards monitor physicians' practices in the hospitals

and exert pressure on physicians' practice behavior.

159

Physicians' own personal standards, ego needs, altruistic
aims, and economic motivations all contribute to maintaining
an acceptable distance to the cutting edge. Finally,
subspecialists like the cardiologist in this study, who rely
on consults and referrals, are extremely dependent on the
medical community's perceptions of them as being close to
the cutting edge. This necessitates that they be more
informed and up-to-date than their colleagues.

The following illustration (Fig. 3) demonstrates the
relationship between the elements of a private medical

practice.

 

 

 

 

 

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cutting edge

 

 

 

 

 

 

 

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Fig. 3

The vertical line on the right indicates the cutting edge of

medicine. This line is characterized by a constant state of

160
change, as it progresses toward the right. The linearity of
the line depicted here should not be construed as
representing a uniform state of progress in all aspects of
medicine nor does it suggest there is always a definitive
division between standard practice and the unknown. Figures
A, B, C, and D symbolize typical private medical practices.
The scope of the practice is indicated by the relative size
and shape of the figure. For instance, the larger the
figure the broader the scope of practice. The distance of
the figure from the vertical line represents the proximity
to the cutting edge. The depth of practice is represented
by the density of the vertical lines within the figure. The
greater the density of lines, the greater the depth of
practice.

It is essential to understand that each practice type
occupies a necessary and useful position in a health care
delivery system. Each is highly dependent on the others.

No relative value or merit can be affixed to a practice
based on its elements of scope, depth, or proximity to the
cutting edge.

Physician A's practice, like those of Dr. 105, Dr. 108,
and Dr. 119 in this study, is typified as being broad in
scope, at least within the context of the specialty. This
physician practices well within acceptable limits but for
the most part acts conservatively, prefers not taking risks,
and does not particularly like making changes or perhaps has

other priorities that preclude expending the effort required

161

for making changes. Physician A prefers to wait until the
"authorities" have sanctioned a practice or lets "near
peers“ do the experimenting. The distance from the cutting
edge and subsequent lack of depth, necessitates a broad
scope of practice. To maintain a practice at this level of
depth requires a scope that is broad in nature as the
physician cannot rely on referrals, consults or reputation
to support the practice. This physician must serve a
larger, more diverse population which is typical of the
general internist and general obstetrican/gynecologist seen
in this study.

Practice C is characterized by a narrow scope, great
depth, and functioning close to the cutting edge.
Physicians in this type of practice are risk takers, enjoy
challenges, rely more on their own experiences and
judgments, are highly committed to the medical practice, and
are up-to-date on all the latest thoughts and practices in
their specific area. These physicians rely greatly on
referrals and consults from other physicians. In this
study, some physicians belonging in this group include those
subspecialists in hematology, nephrology and oncology.

Circle B represents variations between practices A and
D, that is, varying degrees of specialization.

Practice D is typical of many physicians whose practice
is relatively broad in scope but function at a deeper level
in one aspect of practice. Within this specific area of

practice this physician functions closer to the cutting

162
edge. This type of practice may be a result of a
physician's personal interest or a need within the
community. Several internists studied such as Dr. 120,
belong in this group because of their efforts to expand from

a more general practice into a specific area like diabetes.

I] E J E I . . El . . , E I.

Physicians' learning activities are an integral part of
a private medical practice. Learning is not just done in
addition to other practice behaviors. It is routinized in
the very nature of a practice. Hence, learning both shapes
and is shaped by many other influencing factors and plays an
important role in determining the scope and depth of a
practice.

According to the findings of this study, each physician
builds his or her own information network through which he
or she acquires knowledge. This network evolves along with
the developing practice and usually includes journals,
colleagues, subspecialists, meetings, allied health
professionals, continuing medical education programs,
textbooks, and courses. It is this network that establishes
a knowledge base which in turn determines the boundaries of
a medical practice. The extent of the information network
is parallelled by the practices' scope, depth, and distance
from the cutting edge. For instance, a physician cannot
realistically practice outside the scope of an established

practice without a sufficient knowledge base. If a practice

163
is to move in a particular direction, a corresponding change
in the information network must occur. Furthermore, just
keeping a practice at a steady pace with the cutting edge
requires maintaining an active information network.

While the information network does define the practice,
it generally does not extend beyond the scope of practice.
There is a point of diminishing returns where a further
learning investment will not yield any greater benefit to
the practice. In fact, it may actually detract because
there will be less time spent at income generating
activities. Most physicians' lives are too busy to extend
their knowledge base far beyond practical use. For most
physicians, maintaining an up—to-date knowledge base
congruent with the scope of their practice is in itself a
challenge.

An information network begins developing early in a
physician's training. Physicians spend many years
establishing a general base of knowledge which will allow
them to function as independent agents in a private practice
health care system. As the physician progresses, the nature
of the practice and corresponding information network become
more defined. The physician gradually establishes an
information gathering routine which includes specific
sources of information such as certain journals and a group
of trusted colleagues. Although the information network
does develop into a fairly stable behavior pattern, the many

other influencing factors in a practice such as competition

164
and the medical-legal climate do create a degree of
instability. This requires physicians to periodically
adjust or alter their information network depending on the
needs of their practice.

Evidence from this study suggests that most physicians
establish an information network including a filing, storing
and retrieval system, which is integrated into a daily
routine. Thus, learning becomes a routine of practice.

Most physicians described their learning habits as a matter
of picking and choosing from a voluminous information base
what they feel is important to their practice. Usually,
those areas pursued are case related. As information is
presented through the information network, physicians select
those tOpics relating to areas which they encounter most
often, feel deficient in, or pose a particular current
problem to them. Other reasons for topic selectivity may
involve anticipated needs, desire to expand the scope of
practice, or fear of a medical-legal problem. One instance
where physicians do extend beyond their information network
is when preparing for a lecture, presentation, or teaching
experience. These activities require the physician to seek
out information rather than waiting to be exposed to it.
Another instance where physicians go beyond their
information network is when they need to make a change in
their practice that cannot be accomplished within the limits
of their knowledge base.

Physicians' information networks and learning behaviors

165
can be further illustrated by viewing them in relation to
the practice behavior paradigm. The type of routine
learning activities required to maintain practices A, B, C,
and D differ. Physicians whose practices are characterized
by practice A generally look for review articles when
reviewing a journal. This search covers a broad range of
topics. Likewise, when choosing a conference or lecture to
attend, these physicians will seek out known authorities who
provide an up-to-date review of a particular topic.
Practice A type of physicians must be familiar with advances
in many area but do not necessarily need to know all the
specifics. Their knowledge base should be great enough to
at least make the appropriate referral or consult in areas
that are not routine to their practice.

Practice D type of physicians are subspecialists who
keep in touch with general medicine but focus mainly on very
specific detailed information concerning their area of
expertise. When reviewing a journal, these physicians may
read the abstract of a review article but will more than
likely read and file a detailed article which pertains
directly to their practice. Subspecialists must be more
informed in their particular area than anyone else in the
community, even at the expense of having a broader knowledge
base. Most of these physicians' patients have been referred
to them by another physician so the patients' broader health
concerns have already been considered.

Physicians in a practice D situation share

166
characteristics with physicians in both practice types A and
C. These physicians still maintain a fairly broad scope of
practice but do have an area of medicine they specialize in.
A physician may, for instance, have a large number of
patients who are diabetics. As a result, this physician
will pay more attention to information related to diabetes
than other physicians. This learning behavior reinforces

the specialization.

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Most changes physicians make are a result of knowledge
gained through their information network. In the constant
effort to keep pace with the cutting edge, physicians
routinely identify aspects of their practices that can be
improved or up-dated. Other reasons for making changes may
include those which are externally forced on the practice
such as changes in hospital procedures, laws, the type of
clinical problems encountered, and insurance policies.
Physicians may also make a conscious effort to change the
scope of their practice. Regardless of the reason for the
change, actions must be taken to incorporate that change
into practice. To varying degrees, this requires physicians
to engage in some learning activities.

Changes physicians make in their practice differ
greatly from one another. Some changes are small, can be
implemented immediately, and have very little influence on

the other aspects of the practice. Others are more complex,

167
take more effort, and have a large impact on the rest of the
practice. Some changes are within the scope of a practice
while others push the practice into new areas.

There are different reasons for making changes.

Changes must be viewed with respect to psychological,
social, economic, and political factors that influence the
change process from the onset. These factors control why
the change is initiated, how it is to be acquired, and what
effect it will have on the physician and the practice.
Physicians' response to change will differ depending on all
the many variables affecting their practice. For instance,
if the “authorities" have determined a new standard
procedure, a physician may, for fear of liability,
immediately adopt that change with little investigation. On
the other hand, a physician, contemplating the purchase of
an expensive piece of equipment, has a complex problem to
solve. This physician must determine if the change will
make the practice more competitive, if it can be
accommodated in the office, to what extent the new equipment
can be used, which one is the best buy, and what is the
cost-benefit ratio.

Just as each change differs from another, so do the
learning activities associated with these changes. Learning
activities for some changes may be very few and can be done
within the established information network. Other changes
may require extensive learning efforts and extend beyond the

physician's normal learning patterns.

168

The nature of change and its associated learning
activities in a private medical practice is diverse and
complex. There are many influencing factors affecting both
the change and the practice. Change should not be viewed as
a single process composing part of a physician's practice.
Changes and their associated learning activities may be
grouped, based on commonalities; however, it is unlikely
that a uniform pattern or model can be used to explain or
predict how a physician will behave in practice. It would
be more useful to consider a change and its learning
activities in relation to the scope of practice, its depth,
distance from the cutting edge, and the many influencing
factors affecting the practice. Hence, individual instances
of physicians' change and learning behaviors are best
conceptualized as part of a broader practice behavior
pattern rather than a separate developmental process

impacting on a private medical practice.

EHEEALY

As a result of this description of
obstetrician/gynecologists and internists' practice
behaviors, the following hypotheses can be established. Due
to the research methodology used, these hypotheses are
limited to this study population.

1. Physicians' practice behavior can be examined

using a grounded research methodology and yield

substantive theory. This qualitative analysis of

behavior establishes a framework for identifying
changes and learning activities associated with changes

169

made in practice. The ability to develop the research
format throughout the study provided the flexibility
needed to move the research in directions not forseen
at the onset of the study. This is especially
important when studying an area in which little
previous research has been done.

2. The interview technique is a useful tool for
obtaining data when studying physicians' practice
behavior. The form of the interview was able to be
changed to accommodate the nature of the grounded
research methodology. Also, data pertaining to
specific subject areas could be obtained from several
physicians which contributes to the validation of the
findings.

3. Change and its associated learning activities are
integral parts of a practice, both influencing and
being influenced by the many other factors affecting a
practice. Each change influences a practice in a
unique way and is best viewed in relation to the
various elements of a practice rather than part of a
general change process impacting on a medical practice.
Contrary to models proposed by others, there is no
evidence, based on this study, supporting a
predetermined sequence of behaviors comprising a change
process which accounts for all change activities
occurring in a private medical practice. Different
change types require different learning activities and
actions.

4. Physicians are constantly in a state of alertness
for information that is pertinent to their practice and
keeps them up-to-date. This behavior is routinized in
the very nature of the medical practice. Physicians
constant alertness keeps them continually exposed to
new information. They receive journals, attend
meetings, participate in hospital activities, and
consult with colleagues and subspecialists, all as part
of their medical practice experience. Most physicians
are aware of an innovation, at least in their own area
of expertise prior to its general acceptance.

5. Physicians are stimulated to learn and change as a
result of altruistic motivations such as doing the best
thing for the patient, economic motivations, peer
pressure, ego needs for achievement, competition, and
fear of legal problems or loss of practice.

6. Physicians establish an information acquisition
network as part of their routinely keeping informed and
up-to-date practices. This network provides the
knowledge base which in turn defines the boundaries of

170

the medical practice. Physicians must operate within
their knowledge base because of peer pressure, need to
maintain a credible reputation, competition, altruistic
motivations, and medical-legal considerations. This
information network develops and changes as the
practice grows and matures. Also, just to maintain a
practice at a constant level (scope, depth, and
proximity to the cutting edge) requires an active
information acquisition network.

7. Physicians handle the large amount of information
they routinely encounter by selecting those things that
are most important for maintaining their practice.

This method continuously shapes the knowledge base
which subsequently defines the nature of the practice.

8. Journals provide the primary source of new
information for physicians. Different groups of
physicians seek different kinds of information from
journals. Physicians in a more general practice are
inclined to seek review articles than subspecialists,
who select more specific information such as clinical
trial reports.

9. Most learning activities physicians pursue have a
direct practical application to their practice.
Physicians are too busy to spend much time learning
information that is not relevant to their practice.
Most of the learning activities physicians pursue
during their routine information acquisition activities
are in areas of their practice in which they feel a
deficiency. Physicians may pursue an area, however, in
which they anticipate a need. Additionally, when
physicians engage in routine information acquisition
activities such as reading journals, their choice of
subjects depends on the source of information, its
credibility, degree of authority, and extent of
experience.

10. Most learning activities are a result of a
physician's routinized information network, hence,
physicians are basically reactive rather than proactive
learners. For the most part physicians wait until they
encounter information through their information network
rather than actively pursuing knowledge. In order to
maintain a viable, competitive practice, this requires
establishing and sustaining an active information
acquisition network.

11. Physicians develop their own personalized
mechanisms for identifying, filing, storing, and
retrieving information which is considered relevant to
their practice. These resource libraries are an

171

extension of the physician's internal knowledge base
and are part of the routinized information acquisition
network.

12. Physicians' teaching activities provide one of the
major sources of learning that occurs outside their
established information acquisition network.

Presenting a lecture or topic review often requires an
active pursuit of information which may extend outside
the realm of information deemed of practical use. It
may also require actively seeking information which
lies outside their established information storage and
retrieval system.

13. Following the implementation of a change,
physicians use both their own experiences and their
information acquisition networks to continue to learn
more about the new practice. Subspecialists tend to
rely more on their own experiences than do physicians
in a more general practice.

14. Physicians' willingness to tolerate uncertainty,
assume responsibilty for decisions, rely on their own
experiences, and keep up-to-date, all determine the
nature of a private medical practice. Physicians'
practices differ with respect to the scope or extent of
the medical field in which they function, the depth of
knowledge and training within each area of practice,
and by how close to the frontier of knowledge or
cutting edge they practice. These personal qualities
to a great extent, determine what type of practice will
develop.

15. The scope and depth of a private medical practice
are inversely related. As the scope or extent of the
medical field encompassed by the practice increases, it
becomes more difficult to maintain a great depth of
knowledge in every area. Conversely, as the scope
narrows, the depth increases. Specialization, or
narrowing the scope of a practice, reduces the
impossible task of maintaining a large knowledge base
in multiple areas.

16. Influencing factors such as peer pressure,
competition, the medical-legal climate, and altruistic
motivations force physicians to maintain their
practices at an acceptable distance to the cutting
edge. If a physician's practice falls behind, any or
all of these factors could either force up-dating or
termination of practice.

17. The depth of a practice and proximity to the
cutting edge are directly related. As physicians'

172
knowledge base increases, it becomes more up-to-date.
For instance, subspecialists' narrow scope and great
depth necessitates being very close to the cutting edge
if they are to be considered area experts and
subsequently maintain a referral based practice.
18. Physicians practicing close to the cutting edge
rely more on their own trial and error experiences,
seek the latest experiences of their colleagues, and
pursue journal and meetings focused on the latest
developments in a narrow specific area. These
physicians are willing to practice in areas of
uncertainty. Physicians further from the cutting edge
prefer less reliance on their own experiences and would

rather use practices which have been sanctioned by
authorities or supported by a large volume of evidence.

I J' I.

There are several implications concerning this study
that should be discussed. These include the future use of
the research methodology, the usefulness of these findings
in promoting and facilitating change in physicians'

practices, and related areas of future investigation.

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The basic concept of the grounded research methodology
is to begin an investigation by initially drawing
conclusions based on empirical data obtained from just a few
study groups. From this point, additional groups are
observed in an effort to both expand and further define the
initial findings. As a result, the empirical data drawn
from each group is elevated to a conceptual level and it is
at this level that the study groups are compared. From this
analysis of conceptual data, formal theory, with a greater

power of generalization, can be established.

173

It has been demonstrated in this study that grounded
research methodology has been useful in providing an initial
view of physicians' change behavior and learning activities
associated with change. These findings have been elevated
to a conceptual level but await further comparative analysis
with other study groups in order to establish formal theory
about physicians' change behavior. Therefore, in keeping
with the grounded research methodology, the next step in
this investigation would be to study several more private
practice specialty groups, then study physicians practicing
in a different setting such as a health maintenance
organization or academic medicine. This would serve to
better substantiate the private practice change behavior and
also determine if there are unifying elements of change
behavior common to all physician groups. If common elements
were identified, the next step in the grounded research
methodology would be to compare physicians' behavior to that
of other professional groups such as architects, accountants
or attorneys. 'This could result in a formal theory
regarding how adults in professional careers respond to

change.

E J' I.
The insight gained from this study about

obstetrician/gynecologists and internists' practice behavior
and learning activities could be used to facilitate and

promote change within these specialty groups. For instance,

174
it would be useful to understand the nature of the target
population with special attention to their scope of
practice, depth, and proximity to the cutting edge, prior to
initiating change efforts. Also important to know is how
and why physicians make changes, what learning activities
they engage in, and what are the influencing factors
affecting the practice. Using this knowledge to develop a
practice based approach, an effective strategy for
implementing change could be accomplished. This differs
form a change process approach where the emphasis is placed
on providing the correct information to the target
population, in the proper sequence, at the appropriate time,
and by the most useful communication channel. These
techniques would be helpful in addition to, but not

independent of, a practice base approach.

WWW

There are several topics concerning change and learning
behavior identified in this study that are worthy of future
investigation. Most notably is the development and use of a
physician's personal library. Physicians' personal
libraries play an important role in determining the
parameters of a medical practice. It would be useful to
know how physicians determine what information will be saved
amd how it will be stored and organized. Also of importance
are what mechanisms physicians have for retrieving the

information, under what conditions do they use their

175
libraries, and to what extent. This knowledge would be
useful for physicians wanting to develop or improve their
information storing system. Disseminators of information
could also benefit by knowing how to present materials that
can be easily assimilated into a physician's private
library.

A second area of further investigation involves
identifying the role of teaching in the process of change
and associated learning behaviors. Many physicians cited
teaching as one of the primary non-case related reasons for
learning. Understanding the extent of the relationship
between teaching and learning would be useful to many areas

of medical education, as well as adult learning in general.

APPENDIX A

ROGERS' CHANGE MODEL

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176

APPENDIX B

PHYSICIAN PROFILE

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177

APPENDIX C

LETTER OF INVITATION

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Letter of Invitation

(date)

(name)
(address)
(csz)

Dear Dr. (name)

Would you help us? We are beginning an educational research
project that examines how physicians go about making changes
in their practices. The primary emphasis of the
investigation is adult learning. We will accomplish this
task by interviewing 20 OB-GYN physicians in the (name of
city) area. We hope you will consent to be a part of the
study.

As a participant, you will be asked to identify recent
changes made in your medical practice and to explain in
detail the processes that led to the adoption of those
changes.

Initially this will involve an hour-long interview in which
two or three changes will be examined. A follow-up
interview may also be necessary to provide further
clarification and to obtain your reactions to research
findings.

Upon your consent to participate, you will be contacted for
an appointment. To facilitate the interviewing process it
would be helpful if, prior to the interview, you would think
about some changes which have occurred in your practice and
list them. These changes can involve any aspect of your
medical practice such as those involving a new technology,
treatment, or diagnostic methodology. These changes can be
of any magnitude. They do not need to be the most
outstanding change you have made.

Enclosed is a postcard for your reply. If you have any
questions concerning the project, please contact either of
us at the (name) office (phone). Thank you for your
consideration and we look forward to your participation in
the project.

Sincerely,

(name) (name)

Ph.D. Candidate (title), (school)

Adult and Continuing (title), (organization)

Education, (school)

178

APPENDIX D

SECOND LETTER

Second Letter

(date)

(name)
(address)
(csz)

Dear Dr. (name)

On (date) you were invited to participate in a research
project involving physician learning activities associated
with changes made in medical practice. We are approximately
half way through the project and are now awaiting consent to
participate from the remainder of those invited.

Your involvement will include an hour-long interview in
which we will discuss how you have gone about making several
changes in your practice. We do have some time restrictions
and would like to complete the interviewing stage of the
project in the near future. Would you please consider
participating? You may send in the card provided or have
your office call (phone) at (name of organization) to
schedule an appointment.

Thank you for your consideration and we are looking forward
to including you in our project.

Sincerely,

(name) . (name)

Ph.D. Candidate (title), (school)

Adult and Continuing (title), (organization)

Education, (school)

179

APPENDIX E

INTERVIEW OUTLINE

INTERVIEW OUTLINE

E' I I I . C I

l)

2)

3)

Identify as many changes as you can which you have made
in the last two years in each of these catagories.

a.

administrative/office procedure (writes up drugs
generically)

drug use (any new drug or new use of an existing
drug)

patient relationship and education (providing
genetic counseling)

technical aspect of diagnosis (ultrasound in aortic
aneurysms)

diagnosis approach (makes nutritional assessment of
patient)

technical aspect of management (recommend continuous
insulin infusion)

management approach (gives fewer drugs, treats
coronary artery disease more aggressively)

own education

List all your information sources.

Of all the new things that you come across each year,
what percent of them do you actually incorporate into
your practice?

180

181

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

(name of change) was a change you made within the last
two years. Go back to a time before you had any
knowledge of this change. How did you deal with this
situation?

Compared to all the other activities in your practice
you engage in, would you say that you were less than
satisfied, satisfied or more than satisfied with

what you were doing?

When did you first learn about the change?

How did you first learn about the change?

What prompted your first learning of this change? Were
you actively seeking the solution to a problem or did
it come about as part of your routine keeping informed
and up-to-date practices?

Why did you happen to pick this particular change?

Did you acquire additional information after first
learning of the change?

What did you do to learn more about the change? Was
it actively or passively acquired?

How long did it take you to decide to change? When
did you decide to change?

What influenced your decision the most to adopt the
change?

From the time you decided to change to the time you
actually implemented the change, did you pursue any
learning activities? What were they?

What activities have you been involved with in
conjunction with this change since its adoption?

182

I)’ i . I . I

l)

2)

3)

5)

6)

7)

8)

When you pursue a journal or listen to a speaker etc.
what motivates you to pursue one of the many things
that you are confronted with?

Within the last year what practice or activity were you
so displeased with that you actively sought a change?

Think of all the different learning activities that you
engage in. List the major categories. For instance:
a) patient care and treatment b) business aspect of
your practice c) leisure activity d) family

e) personal growth

Prioritize these categories in terms of the amount of
time and energy spent in each.

Do you set aside a time for learning? How much time?
When? What type of things do you learn during this
time?

Do you find that this amount of time just keeps you
caught up or are you able to pursue areas of interest?

What are these areas of interest? Lately what have
you pursued?

What motivates you to pursue learning in these areas?

APPENDIX F

POST-INTERVIEW FIELD NOTES

Post-Interview Field Notes

Dr. 111
1:15 May 22, 1984

Dr. 111 was most cooperative and was willing to give as
much time as the interview required. The interview lasted
for about an hour and a half although there were several
telephone interruptions.

What struck me the most about Dr. 111 was his patient
oriented learning activities. In the evenings Dr. 111
investigates the various cases he encounters during the day.
This usually involves textbook reading. He also encourages
his residents and medical students to do this as well. Dr.
111 believes this is important even if you have read the
information before.

Dr. 111 finds the conferences that he conducts to be
quite educational in that he does prepare for them by
reading and investigating up-to-date information. To do
this, he uses the library frequently.

While studying (local hospital) as an educational
organization prior to this study, I had the opportunity to
observe Dr. 111 in one of his group conferences. He indeed
was both a learner and a teacher.

183

APPENDIX G

TRANSCRIPTION FORMAT

Dr. 111:

Interv:
Dr. 111:
Interv:

Dr. 111:

Interv:

Dr. 111:

Interv:
Dr. 111:
Interv:

Dr. 111:

Transcription Format
(example)

I can only guess that it was used about a year
ago, soon after it was released. There was the
one single patient--just the worse ulcers that
wouldn't even get better, proven ulcers that were
refractory to Tagamet. So even the Tagamet wasn't
getting this lady's ulcers better. I gave her the
Zantac and she seemed a little better--it seemed
to help. We were kind of happy, and she certainly
wasn't having any side effects with Tagamet, and
Zantac didn't give her any side effects either.
She couldn't tell too much difference but she
seemed a little better.

So you learned about it two to three years ago,
and then a year--a little over a year ago, it was

released.
Soon after its release I tried it on one patient.

You didn't have access to it before that?

No access to it before that. So soon after its

release it got used

What influenced your decision the most to adopt
the change?

To use that was the hope that it might be free--
have fewer side effects; that was the primary
thing. More than anything else, the hope--I will
not say that I believe it's proven yet.

So there are no authority figures or endorsing
organization or anything like that, that
influenced you?

No, nothing of that sort. No

Or colleagues?

No. No, it wasn't colleagues, it was--oh, I take
that back. I turned to my gastroenterology

associates who specialize in GI and I did discuss
with two gastroenterologists.

184

Interv:

Dr.

111:

Interv:

Dr.

111:

Interv:

Dr.

111:

185
Before you used it?

Before I used it, to make sure that they felt it
was legitimate, safe, because this is not my
field, and they did. They said that they seemed
to know as much as I knew, which was that the
literature said that it's supposed to be safer.
They were as skeptical as I was.

Since you've started using it, what have you done
in terms of continuing your education about it?

Well, okay. Once again, when I see articles I

may actually sit down and read the article, you
know, if there should be one. The definitive
article has not been written. In other words, the
first year's experience throughout the nation--
somebody's going to have to write that article,
and say, ”Now we've learned this; now that a
million people have taken it we've learned this.“

You're going to be looking for this article?

I'm watching for such an article. When it's
written, I won't skim it--I'll read it, just
because I'm using the medicine, so I wonder, is it
really effective, does it really have fewer side
effects?

APPENDIX H

THANK YOU LETTER

Thank You Letter

(date)

(name)
(address)
(csz)

Dear Dr. (name)

I would like to thank you for your participation in the
adult learning research project. Data from our (date)
interview has been coded to assure your anonymity and I am
now in the final stages of data collection. The next step
of the project will be to compare and contrast the various

responses.

Through your cooperation I have been able to gain insight
into how and why physicians acquire new information and go
about making changes in their practice.

I appreciate the many demands you have on your time and
again thank you for your willingness to be interviewed. I
hOpe that you were able to also find value in your
introspective look at learning activities associated with

your practice.

Sincerely,

(name)

Ph.D. Candidate
Adult and Continuing
Education, (school)

186

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