Additional Investigations and Referrals by Primary Care Physicians in Uncertain Clinical Situations: Cross-Sectional Study Using Virtual Patient-Based Scenarios.

Background: Uncertainty affects at least 20% of primary care consultations, possibly leading primary care physicians to order additional investigations or referrals, affecting cost-effectiveness and patient safety. Experience is a key determinant in making these orders, along with anxiety or physicians' reactions to uncertainty. Past studies addressing the links between experience and additional investigations and referrals in uncertain situations have used questionnaires, database analyses, or interviews with general practitioners, but no study has used fully standardized conditions. Objective: This study aimed to examine the association between experience and orders for additional investigations and referrals in uncertain situations using a standardized virtual patient simulation. Methods: A cross-sectional study was conducted with 40 physicians stratified by sex and experience (<10 vs ≥10 years). Participants engaged in a simulated clinical scenario involving a man aged 69 years with atypical dyspnea designed to evoke diagnostic uncertainty. The virtual patient was presented via first-person video to assess the physicians' decision-making process. Participants' years of clinical experience, sex, age, place of practice, type of practice, number of in-office patients, duration of consultations, State-Trait Anxiety Inventory Form Y (STAI-Y) and Physician Reaction to Uncertainty scores, and diagnostic hypotheses were collected and analyzed using multivariate regression models. Results: The group with <10 years of experience had higher STAI-Y (mean 41.3, SD 6.8 vs mean 32.7, SD 8.2; P<.001) and Physician Reaction to Uncertainty (mean 20.7, SD 5.4 vs mean 14.4, SD 6.9; P=.002) scores. Participants with <10 years of professional experience ordered more additional investigations and referrals 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 on costs: €153.80 (US $173.45) vs €129.60 (US $146.16) (effect size 0.296, 95% CI -0.348 to 0.939; P=.23). Multivariate analysis showed an association between the number of additional investigations and referrals with age (relative risk 0.980, 95% CI 0.963-0.997; adjusted P=.02) and mean STAI-Y score (relative risk 0.984, 95% CI 0.968-0.999; adjusted P=.04) but not with experience (<10 vs ≥10 years; R2=0.308). Conclusions: Less experienced physicians do not appear to overly rely on additional investigations and referrals in uncertain situations, suggesting that clinical reasoning remains a well-preserved skill among the younger generation of physicians. Future research could explore interventions targeting physicians' anxiety and tolerance to uncertainty as potential factors influencing requests for additional investigations and referrals. In practical terms, two avenues could be explored: specific training for supervisors to help them address uncertainty tolerance in the feedback they provide to trainees and the use of virtual consultations as a complement to traditional training, with particular attention to this aspect.