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Exploring the Gap Between Knowledge and Behavior: A Qualitative Study of Clinician Action Following an Educational Intervention

Kennedy, Tara MD, MEd; Regehr, Glenn PhD; Rosenfield, Jay MD, MEd; Roberts, S Wendy MD; Lingard, Lorelei PhD

Special Theme Research Report

Purpose. Many medical education interventions improve clinicians’ knowledge but fail to change behavior. The authors exposed this knowledge–behavior gap through standardized clinical interactions, thus allowing in-depth exploration of the contributing factors.

Method. A typical evidence-based educational intervention in one clinical domain (early signs of autism) was administered to family medicine residents at the University of Toronto in 2001–02, and change in knowledge was assessed through a multiple-choice test. Six to eight weeks later, participants’ relevant knowledge was documented, and their clinical behavior was observed during four interactions with standardized patients. Factors producing a knowledge–behavior discrepancy were then explored using semistructured interviews, which were audiotaped, transcribed, and analyzed using grounded theory methods.

Results. Half of participants demonstrated varying degrees of knowledge–behavior gap. Eight main rationalizations (relationships, patient agenda, knowledge deficit, clinical style, means to an end, ideals, autism stigma, and systems barriers) were used to justify choices of clinical behavior, and the same rationalizations were used to justify opposite choices of behavior. Two conditions that promote clinical action based on knowledge (level of certainty and sense of urgency) were identified.

Conclusion. The knowledge–behavior gap was exposed and factors reported to influence clinicians’ decisions about whether to implement new knowledge were elicited. That identical rationalizations were used to justify opposite behaviors implies these factors may not be behavioral determinants. Sense of urgency and level of certainty promote clinical action based on knowledge; focusing on these may increase the impact of education on practice.

Dr. Kennedy is a developmental pediatrician, Bloorview MacMillan Children's Centre, and assistant professor, Department of Pediatrics, University of Toronto. Dr. Regehr is the Richard and Elizabeth Currie Chair in Health Professions Education Research; associate director, Wilson Centre for Research in Education; and associate professor, Department of Surgery, University of Toronto. Dr. Rosenfield is a developmental pediatrician, Child Development Centre, The Hospital for Sick Children; director, Curriculum, Undergraduate Medical Education; and associate professor, Department of Pediatrics, University of Toronto. Dr. Roberts is medical director, Child Development Centre, Hospital for Sick Children, and associate professor, Department of Pediatrics, University of Toronto. Dr. Lingard is assistant professor, Department of Pediatrics, and educational scientist, Wilson Centre for Research in Education, Faculty of Medicine, University of Toronto, Ontario, Canada.

Correspondence and requests for reprints should be addressed to Dr. Tara Kennedy, Centre for Research in Education, University Health Network, 200 Elizabeth St., Eaton South 1-565, Toronto, Ontario, Canada M5G 2C4; e-mail: 〈tara.kennedy@utoronto.ca〉.

© 2004 Association of American Medical Colleges