Accepted for/Published in: JMIR Formative Research
Date Submitted: Jan 24, 2025
Date Accepted: Feb 10, 2026
Additional Investigations and Referrals by Primary Care Physicians in Uncertain Clinical Situations: Virtual Patient–Based Cross-Sectional Study
ABSTRACT
Background:
In primary care, approximately 20% of consultations occur in uncertain situations, prompting physicians to request additional investigations or referrals (AIR) to aid decision-making. While optimal management of AIR is crucial for cost-effectiveness and patient safety, younger practitioners are often criticized for overusing AIR. Experience and other factors such as anxiety, practice conditions or societal pressures have been linked to AIR usage. However, no study has explored these relationships under standardized conditions.
Objective:
To examine the association between experience and AIR requests in uncertain situations using standardized virtual patient simulations.
Methods:
A cross-sectional study was conducted with 40 primary care physicians (PCPs) stratified by sex and experience (<10 vs. ≥10 years). Participants engaged in a simulated clinical scenario involving a 69-year-old man with atypical dyspnea, designed to evoke diagnostic uncertainty. Participants’ number of years of experience, sex, age, place of practice, type of practice, number of in-office patients, duration of consultations, State-Trait Anxiety Inventory (STAI-Y) and Physician Reaction to Uncertainty (PRU) scores and diagnostic hypotheses were collected and analyzed using multivariate regression models.
Results:
The group with under 10 years of experience had higher STAI-Y and PRU scores (respectively 41.3 vs 32.7; P=<.001 and 20.7 vs 14.4; P =.002). Participants with under 10 years of professional experience ordered less AIR on average: 10.2 (SD 3.4; 95%CI [8.9 - 11.7]) vs 8.1 (SD 3.7; 95%CI [6.5 - 9.9]; P=.03). There was no effect in costs: €153.8 versus €129.6 (P=.03; effect size 0.296 [-0.348; 0.939]). There was no effect of experience in multivariate analysis
Conclusions:
Contrary to prior assumptions, younger PCPs do not overly rely on AIR in uncertain situations, suggesting that clinical reasoning skills remain robust. Future research should explore interventions to reduce anxiety and enhance tolerance to uncertainty.
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