Family Practice Vol. 19, No. 6, 617-622
© Oxford University Press 2002
Asking for ‘rules of thumb’: a way to discover tacit knowledge in general practice
a Centre for Clinical Research, Nissers väg 3, 791 82 Falun, Sweden,
b Department of Medicine and Care, Primary Care, Faculty of Health Sciences, Linköpings universitet, 581 85 Linköping, Sweden,
c Unit of Research and Development in Primary Care, 551 85 Jönköping, Sweden.
Malin André; E-mail: Malin.Andre{at}ltdalarna.se
André M, Borgquist L, Foldevi M and Mölstad S. Asking for ‘rules of thumb’: a way to discover tacit knowledge in general practice. Family Practice 2002; 19: 617–622.
Received 4 December 2001; Revised 9 May 2002; Accepted 16 July 2002.
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Abstract |
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Background. Research in decision-making has identified heuristics (rules of thumb) as shortcuts to simplify search and choice.
Objective. To find out if GPs recognize the use of rules of thumb and if they could describe what they looked like.
Methods. An explorative and descriptive study was set up using focus group interviews. The interview guide contained the questions: Do you recognize the use of rules of thumb? Are you able to give some examples? What are the benefits and dangers in using rules of thumb? Where do they come from? The interviews were transcribed and analysed using the templates in the interview guide, and the examples of rules were classified by editing analysis.
Results. Four groups with 23 GPs were interviewed. GPs recognized using rules of thumb, producing examples covering different aspects of the consultation. The rules for somatic problems were formulated as axiomatic simplified medical knowledge and taken for granted, while rules for psychosocial problems were formulated as expressions of individual experience and were followed by an explanation. The rules seemed unaffected by the sparse objections given. A GP’s clinical experience was judged a prerequisite for applying the rules. The origin of many rules was via word-of-mouth from a colleague. The GPs acknowledged the benefits of using the rules, thereby simplifying work.
Conclusion. GPs recognize the use of rules of thumb as an immediate and semiconscious kind of knowledge that could be called tacit knowledge. Using rules of thumb might explain why practice remains unchanged although educational activities result in more elaborate knowledge.
Keywords. Decision-making, focus groups, general practice, heuristics.
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Introduction |
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There is a well-known gap between ‘best practice’ and everyday work in general practice medicine. However, this gap is not only an issue of insufficient knowledge. Implementation of evidence-based medicine in everyday work is unpredictable, and it is said that medicine lacks a coherent theory of behavioural change.1
Cognitive psychology presumes that the way people think about a situation determines their behaviour. Frequent and repeated judgements and decisions are said to be automatically processed, while thinking in the face of more complex problems is done analytically.2 In the 1970s heuristics or rules of thumb were looked upon as overused and dispensable cognitive processes that people misapplied when logic and probability theory should be used instead. Recent research has found that heuristics are useful and even necessary shortcuts, guiding search and choice under uncertainty and time constraint. Heuristics are automatic processes and are described as mental shortcuts that simplify relevant information and lessen required mental strain. Fast and frugal heuristics correspond well to probability theory.3 According to this, GPs use heuristics in dealing with everyday problems. The use of heuristics could offer an explanation both for how GPs are able to handle the huge amount of decisions in their everyday work and for their resistance to change. However, studying nurses’ decisions it appears they rely on heuristic strategies when the task is more complex and time is constrained.4 Recording and analysing his own rules of thumb, Ben Essex has created a decision support system aimed at describing the ‘best’ route for decisions in general practice.5 We have not found any other studies of doctors’ use of heuristics. Consequently, it is important to explore GPs’ use of heuristics, and therefore this study was undertaken in order to explore whether GPs recognized the use of heuristics and could give examples.
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Methods |
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Since the study was exploratory, a qualitative study was set up using focus groups. Focus groups are a fruitful way of gathering the maximum information on a topic about which very little is known and are judged invaluable for examining how people think and how ideas operate within a given cultural context.6 The study was approved by the regional ethical comittee.
In forming the focus groups, consideration had to be given to whether the participants should be acquainted with each other or not. As the aim of the study was to explore GPs’ automatic thought processes, and strangers would be inclined to explain taken for granted assumptions, it was decided to invite existing groups of GPs.7 About half of the 140 GPs in the county of Dalarna participated in seven groups for continuing medical education, and the groups were invited to participate in the study. One of the groups declined and a total of four groups were interviewed. The groups worked in different parts of the county and varied in size between four to seven GPs. The participating 23 GPs, 10 females and 13 males, had all worked in general practice from five to twenty years. Recruiting of new groups was stopped when no new items were brought up (saturation). The moderator (MA) was acquainted with all the participating GPs.
The definition given to the GPs of ‘rule of thumb’ was ‘a mental pattern that could be made conscious, used during consultation, was action oriented, used whether or not the background for the rule was understood, and was not based on knowledge of the actual patient (as an individual)’. The moderator, who conducted the interviews alone, introduced the subject and presented the concept ‘rule of thumb’ using the description above. She also gave two examples of her own: ‘When a patient is able to bear weight on a leg it isn’t broken’ and ‘When quicktest (desk-top test for Group A beta-haemolytic streptococci) is positive prescribe phenoxymethylpenicillin’. A guide for the interview had been created beforehand containing the questions: Do you recognize the use of rules of thumb? Are you able to give some examples? What are the benefits and danger of using rules of thumb? Where do they come from? In the discussion, lasting for one to one and a half hours, the moderator followed the guide, confirmed statements and asked for clarifications.
The interviews were audio-taped and transcribed verbatim and were read several times by MA and SM. The templates from the interview guide were used for initial coding while at the same time some new codes emerged. The statements were shortened and rephrased and put in an ordinary text-file and ordered manually. MA and SM independently identified the examples of rules of thumb, which were classified by MA using an editing analysis, keeping notes of the steps of the analysis procedure.8 The coding was discussed between the authors until agreement was reached. The results from the templates and emerging themes were then discussed at meetings with the interviewed GPs.
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Results |
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Rules of thumb were recognized
After a few minutes of initial hesitation the GPs in every group recognized using rules of thumb and produced 30–40 examples of rules per group. In two of the groups there were one or two doctors who only contributed a few rules, but admitted that they used rules, especially dealing with patients with acute illnesses. These doctors also questioned the use of rules of thumb by stating that the patient is always a human being, and the aim of the consultation is for the doctor to discover who that person is.
The doctors tried to define a rule of thumb. They said that the rule appeared immediately to mind and helped simplify and structure their work. They were mental shortcuts. Often a rule was an expression of probability.
"Perhaps we have too few rules of the thumb? That may be why we at times feel that our heads are spinning." D"I guess you are forced to simplify for yourself a little. Put things in order in your life. I couldn’t stand to have such a huge scheme to follow and think of for every patient, so you have to create some shortcuts." R
"I think there are a couple of areas which I have had a little difficulty with . . . which before had been rather simple general outlines. For example, hypertension or blood lipids. With those I have had a relatively simple outline . . . Then it becomes only more and more complicated. Those patients call for more thought and effort . . . I have to be busy thinking almost every time." D
Participants in all focus groups discussed whether the rules were conscious or not and assumed that many of them were unconscious. One of the participants said that the rules functioned unconsciously because their purpose was to save one from thinking. The GPs were astonished at having so many rules of thumb. Differences between routines, guidelines, and rules of thumb were recognized. One doctor described a rule of thumb as "The rule you carry with yourself".
What did rules of thumb look like?
Two major groups of rules were identified: rules for somatic and psychosocial problems. Examples of the rules, covering different parts in the consultation, are given in Table 1
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The largest group of rules dealt with somatic problems (Table 1:1–10
). They all were stated very simply, were content specific and were expressed as axioms without any explanation. They were described as being invariable step-by-step processes. Some of them were expressions of the doctors’ routines as well as routines of the surgery (Table 1:3, 1:4). For the most part, others in the focus groups didn’t object to these statements, even if different doctors postulated different rules for the same problem.
There were also rules to guide the doctors’ communication for psychosocial matters (Table 1:11–1:15). Most of these rules emerged from one focus group. Only a few rules were content specific. The rules were all accompanied by explanations, and were discussed by the colleagues in the group. Some of these rules were used mostly to elicit patients’ opinions (Table 1:13, 1:14). A few examples were also given of when not to use a rule of the thumb (Table 1:16–1:18). Overall, the rules were not affected by the sparse objections given.
Where did rules of thumb come from?
When the GPs discussed where they’d received their rules they mentioned a variety of sources, including medical education, rules from the workplace and their own experience. Some doctors said that they still used some of the warning signals they learned while studying medicine, adding that personal experience was required to be able to use them. When a source of a rule was mentioned at the same time as the rule it almost always was a colleague mentioned by name passing on the rule by word-of-mouth. Several GPs postulated that it wasn’t possible to learn rules of thumb by reading, since medical knowledge very seldom is formulated in that way. They declared it necessary to simplify in order to be able to handle the patient’s problem.
"The textbooks have certainly complicated our lives enormously. If we take chest pains now . . . Before you can conclude that there possibly could be a psychogenic anxiety or something like that in the picture, you first have to exclude ten or fifteen organic causes. But over the years you learn that it doesn’t work to practice that way. Then you are actually forced to work based on shortcuts from your own experience." J
When did rules of thumb change?
The GPs mentioned different reasons for changing their rules (Table 1:2). When medical knowledge and edicts change, as in the case of hypertension and raised blood lipids, or when society acknowledges burn-out and stress as medical matters, the rules change.
"You could say that perhaps we should reassess old rules of thumb . . . Nowadays we’ve learned to look for other things. Exclude sickness and diagnose burn-out and strain and stress and divorce and economical troubles." O
Several doctors mentioned patient complaints and diagnostic mistakes as a reason for change. The doctors did not agree whether the use of rules of thumb increased with clinical experience or not.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionReferences |
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The GPs recognized rules of thumb and produced many examples, covering different aspects of consultation. The rules for somatic problems were formulated as axiomatic, simplified medical knowledge, taken for granted and not inviting discussion, while the rules for psychosomatic problems were formulated as expressions of individual experience and were followed by an explanation. The rules for somatic problems were content specific while most rules for psychosocial problems were not. The rules seemed unaffected by the sparse objections given. The GP’s clinical experience was judged a prerequisite for applying the rules. The origin of many rules was via word-of-mouth from a colleague. The GPs acknowledged the benefits of using the rules, thereby simplifying work. The rules appeared to be a type of immediate knowledge, which was not really conscious and might be called tacit knowledge.
The interview situation using focus groups makes explicit use of group interaction, and judging the validity of the results requires paying attention to what could be acceptable behaviour in the interview situation.7 Asking for rules of thumb in the setting of colleagues implies a diminished risk of theorizing, since verbal embroidery would be noticed. The participants knew the moderator from many years of collegial work, but the discussions went on freely after the first minutes of hesitation, and every group expressed their satisfaction after the session. Although not recommended, the moderator conducted the focus groups alone, and it was occasionally difficult to pay attention to the quieter members of the group. For these people the moderator tried to follow up with direct questions during the interview.
Two of the authors (MA and SM) independently identified the same examples of rules of thumb. It is unavoidable that the results of the coding of the rules reflect the authors’ own conception of reality. Although a systematic analysis was carried out with the joint effort of the involved authors, other researchers might interpret the data differently. To guarantee objectivity the authors in the coding process looked for contradicting data. A few doctors questioned the use of rules stressing the importance of finding out who the patient is, thereby expressing ideas from patient-centered medicine.9 Most rules concerning psychosocial problems emerged from one of the focus groups, although they were recognized by GPs from the other groups in subsequent meetings. As the study was an attempt to explore an earlier not researched domain no effort was made to cover the whole range of work in the consultation. Instead the rules of thumb gathered must be looked upon as examples of mental representations of knowledge. Many situations were not mentioned, for example the patient sick-listed for several months and the older patient with multiple illnesses. The reason for this is unclear—were the GPs influenced by the examples given by the moderator or do these situations require more analytic thinking?
The result of this study is the description of the rules postulated by GPs in the county of Dalarna and can not be generalized as results from a quantitative study. GPs from a different region or with less experience probably would produce different examples. ‘Rule of thumb’ is not a defined entity of knowledge, and during the focus group interviews no clear distinction was made between habit and rule, although consideration has been given to sorting out statements with normative functions.10 The recognition of rules of thumb among colleagues during the group interviews, as well as during subsequent seminars, confirmed rules of thumb as expressions of GP knowledge. Communicating the results through this article is a further step in validating the findings.11 The fact that such rules among GPs have not been described earlier makes further exploration challenging.
The rules used for dealing with somatic complaints were simplified established medical knowledge expressed as clear-cut axioms without reference to any pathophysiological background. The rules for psychosocial problems were all said to be experience based, although many of them could be recognized from lessons on conducting good consultations.9 They helped the doctor to individualize the consultation and widen the focus from the somatic complaint. These two sets of rules correspond to the description by McWhinney of the clinician’s two processes, the individualizing and the generalization process.9 Rules of thumb thus could be examined as empirical evidence of the GP’s clinical knowledge. Discussing the concept of rule of thumb, the GPs acknowledged the different characteristics of the rules. The rules for somatic problems were all content specific. This contrasted with Essex’s elaborated rules used for decision support where over 90% of the rules were not disease specific.5 Rules for not using rules could be looked upon as meta rules. As many rules of thumb were expressions of probability, these rules expressed the demand for caution, notifying the doctor of the constant possibility of unusual problems turning up in general practice.
Models for mental representations of knowledge have been developed from vast research within cognitive psychology. Expertise is associated with knowledge that is largely experimental and non-analytical, where pattern recognition is an essential skill.2 This offers an explanation why the more experienced doctors scored lower than the newly examined in knowledge tests.2,12 The rules of thumb presented in this study could be looked upon as empiric evidence of this type of knowledge from general practice, where prototypical knowledge structures, including pattern recognition that is used in the diagnostic process, build scripts or schemes used in problem solving.2 The attributes of the rules of thumb in this study correspond to those described for heuristics. The decisions were made in stages, thus reducing the amount of simultaneous decisions required of the doctor.3 Using the rules helped the doctor to deal with the inevitable uncertainty in praxis and could explain the higher degree of decisiveness among GPs with longer experience noted in earlier studies.13
The existence of rules of thumb could explain the fact that praxis remains unchanged when knowledge and competence increase as a result of CME activities.1 As the rules are not really conscious, it is possible that they remain unaltered even though more elaborate knowledge develops. Some of the rules appear to be idiosyncratic, thereby offering a possible explanation to the fact that different doctors keep their individual obsolete practice patterns instead of integrating results from new knowledge. Since the use of rules of thumb is for the most part unconscious, it is important for GPs to identify their own rules. Furthermore, to exploit the wording of the rules might be an effective approach to implementing evidence-based medicine. Expressing a rule of thumb often requires abandoning scientific rigour. Even if the knowledge base is complex the rule must be simple and perhaps shared word-of-mouth. In studying the diffusion of new medical technologies the local process is emphasized, along with the importance of word-of-mouth, giving credibility to the new information.14 Words from a colleague were often mentioned as the origin of rules of thumb. The use of rules of thumb might explain why the pharmaceutical industry continues to use travelling sales personnel to spread their messages.15
The different examples of rules of thumb, together with the discussion of when they are used, describe the work of doctors during consultation. Further analysis might give a picture of the decision process during consultation, thus exploring the further possibility of using rule of thumb for education and quality improvement.
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Conclusion |
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Cognitive psychology describes how the skilled person develops mental short cuts/heuristics. This study shows that GPs are able to recognize and verbalize examples of heuristics expressed as rules of thumb from different domains of clinical knowledge. These rules were semiconscious and could probably be called tacit knowledge. Using rules of thumb might explain why practice remains unchanged although educational activities result in more elaborate knowledge. However, to what extent these rules are expressions of knowledge in use and whether they correlate to behaviour are vital and unanswered questions.
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Acknowledgments |
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Thanks are due to the participating GPs and to Dalarna Research Institute for financial support.
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References |
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1 Marteau T, Sowden A, Armstrong D. Implementing research findings into practice: beyond the information deficit model. In Haines A, Donald A (eds). Getting research findings into practice. Plymouth: BMJ Publishing Group, 1998: 36–42.
2 Schmidt HG, Norman GR, Boshuizen HP. A cognitive perspective on medical expertise: Theory and implications. Acad Med 1990; 65: 611–621.[Web of Science][Medline]
3 Gigerenzer G, Todd P and the ABC group. Simple heuristics that make us smart. Oxford: Oxford University Press, 1999: 3–34.
4 O’Neill E. Heuristic reasoning in diagnostic judgement. J Prof Nurs 1995; 11: 239–245.[Web of Science][Medline]
5 Essex Ben. Doctors, dilemmas decisions. London: BMJ Publishing Group, 1994.
6 Morgan D, Kreuger R. The Focus Group Kit, Vol 1. London: Sage Publications, 1998: 9–15.
7 Morgan D, Kreuger R. The Focus Group Kit, Vol 2. London: Sage Publications, 1998: 55–71.
8 Crabtree B, Miller W. Doing qualitative research. Newbury Park: Sage Publications, 1992: 13–21.
9 McWhinney I. A textbook of family medicine. Oxford: Oxford University Press, 1997: 123–155.
10 Wright GH. Norm and action. A logical enquiry. London: Routledge and K Paul, 1963: 1–16.
11 Malterud K. The issue of validity regarding the contents of consultations. Scand J Prim Health Care 1993; 11 Suppl. 2: 64–67.
12 van Leeuwen YD, Mol SSL, Pollemans MC, Drop MJ, Grol R, van der Vleuten CP. Change in knowledge of general practitioners during their professional careers. Fam Pract 1995; 12: 313–317.
13 Westin S. Problem solving styles of general practitioners in simulated clinical situations. Fam Pract 1984; 1: 92–99.
14 Greer AL. The state of the art versus the state of the science. I J Tech Ass Health Care 1988; 4: 5–26.
15 Soumerai S, Avorn J. Principles of educational outreach (‘Academic detailing’) to improve clinical decision making. JAMA 1990; 263: 549–556.
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