title: Contextual factors in clinical decision making: national survey of Canadian family physicians.
abstract: OBJECTIVE
  Many factors are at play in the process of clinical decision making, but to date, the interaction of these factors has not been well understood. Such information could have important implications for teaching and promoting evidence-based medicine (EBM) in primary care. This study was designed to explore the relationship between physician-related variables and management of patient-related contextual factors in clinical decision making. A secondary objective was to examine the extent to which this relationship varies by type of clinical decision.
  
  
  METHODS
  Cross-sectional randomized postal survey of 1134 Canadian primary care physicians stratified by age, sex, and practice location. Nonrespondents were sent reminders at 4 weeks and again at 8 weeks; at 12 weeks, all remaining nonrespondents were mailed replacement copies of the questionnaire.
  
  
  METHODS
  Family practices in Canada.
  
  
  METHODS
  Of the final sample of 431 family physicians, 52% were men, 63% practised in urban locations, and 71% were in group practice.
  
  
  METHODS
  Self-reported likelihood of considering various contextual factors during the course of clinical decision making.
  
  
  RESULTS
  Despite the three follow-up mailings, the final response rate was 42%; however, nonrespondents did not differ significantly from respondents on three important demographic factors: age, sex, and practice location. Using multinomial logistic regression analysis, the data showed that female family physicians and practitioners less strongly identified with EBM were more likely to consider contextual factors in clinical decision making. The effect was more obvious for ordering tests than for decisions about treatment.
  
  
  CONCLUSIONS
  The evolving model of EBM should consider important physician-related variables in clinical decision making. Our data indicate that physicians' sex and identification with the tenets of EBM influence management of contextual factors. These results have important implications because they indicate that clinicians strongly identified with the EBM model of clinical practice are less sensitive to context, which might be an obstacle to efforts to integrate patient values and clinical circumstances into patient-centred care. We believe these findings support continued development of the model of "context-sensitive medicine" previously proposed as an alternative to EBM.
authors.affiliation: Primary Care Research Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ont.
authors.forename: C Shawn
authors.initials: CS
authors.lastname: Tracy
authors.forename: Guilherme Coelho
authors.initials: GC
authors.lastname: Dantas
authors.forename: Rahim
authors.initials: R
authors.lastname: Moineddin
authors.forename: Ross E G
authors.initials: RE
authors.lastname: Upshur
mesh_terms: D000328:Adult; D002170:Canada; D003657:Decision Making; D019317:Evidence-Based Medicine; D005194:Family Practice / Q000706:statistics & numerical data*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*