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BMJ No 7128 Volume 316
Information in Practice Saturday 31 January 1998
General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey
Alastair McColl, Helen Smith, Peter White, Jenny Field
Click here to view full survey questionnaire
Click here to submit your views on EBM with our interactive questionnaire (questions 1 to 7 of the survey questionnaire)
Abstract
Objectives: To determine the attitude of general practitioners towards evidence based medicine and their related educational needs.Design: A questionnaire study of general practitioners.
Setting: General practice in the former Wessex region, England.
Subjects: Randomly selected sample of 25% of all general practitioners (452), of whom 302 replied.
Main outcome measures: Respondents' attitude towards evidence based medicine, ability to access and interpret evidence, perceived barriers to practising evidence based medicine, and best method of moving from opinion based to evidence based medicine.
Results: Respondents mainly welcomed evidence based medicine and agreed that its practice improves patient care. They had a low level of awareness of extracting journals, review publications, and databases (only 40% knew of the Cochrane Database of Systematic Reviews), and, even if aware, many did not use them. In their surgeries 20% had access to bibliographic databases and 17% to the world wide web. Most had some understanding of the technical terms used. The major perceived barrier to practising evidence based medicine was lack of personal time. Respondents thought the most appropriate way to move towards evidence based general practice was by using evidence based guidelines or proposals developed by colleagues.
Conclusion: Promoting and improving access to summaries of evidence, rather than teaching all general practitioners literature searching and critical appraisal, would be the more appropriate method of encouraging evidence based general practice. General practitioners who are skilled in accessing and interpreting evidence should be encouraged to develop local evidence based guidelines and advice.
Introduction
Evidence based medicine is being promoted in general practice as throughout the NHS. General practitioners can attend workshops on how to practice and teach it, research networks promote its use, the Cochrane Library has an increasing number of systematic reviews relevant to general practice, and the journal Evidence-Based Medicineregularly contains summaries of general practice topics. Books on evidence based medicine present common general practice questions, show how to critically appraise papers, and to evaluate different sorts of evidence. Critical appraisal is now part of the MRCGP exam. Recent papers have highlighted the need for evidence based general practice,(1,2) the role of evidence based guidelines in the management of conditions common to general practice,(3-5) and the estimated proportion of interventions in general practice that are based on evidence.(6) One paper has described the problems that may arise in general practice from overreliance on evidence based medicine.(7) These included the potential lack of applicability of the biomedical perspective and the role of opinion in tailoring evidence to a patient's context and preferences.
In the United Kingdom, however, very little is known about general practitioners' attitudes towards evidence based medicine, the extent of their skills to access and interpret evidence, the barriers to moving from opinion based to evidence based practice, and the additional support necessary to incorporate evidence based medicine into everyday general practice. The objectives of this study were to determine the attitude of general practitioners towards evidence based medicine and their related educational needs. Postgraduate tutors, health authorities, and the Wessex Primary Care Research Network (WReN) required this information to inform local strategies aimed at encouraging general practitioners to implement evidence based medicine. Early approaches used in Wessex included workshops on critical appraisal and evidence based medicine and training in performing literature search as part of courses on research methods. After initial local enthusiasm, however, it had become harder to recruit general practitioners to such training events.
To fulfil the objectives of the study we set out to identify general practitioners'
 | Attitude towards evidence based medicine | |
| Awareness and perceived usefulness of relevant extracting journals, review publications, and databases | |
| Ability to access relevant databases and the world wide web | |
| Understanding of technical terms used in evidence based medicine | |
| Views on the perceived major barriers to practising evidence based medicine | |
| Views on how best to move from opinion based to evidence based medicine. |
Subject and methods
In April 1997 we sent a questionnaire to 452 general practitioner principals in the former Wessex region in south England. These represented 25% of all Wessex general practitioner principals obtained from a national database,(8) who were randomly selected by means of random numbers generated by Microsoft Excel with supervision from a statistician.
The covering letter for the questionnaire included a definition of evidence based medicine as the "conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Its practice means integrating individual clinical expertise with the best available external clinical evidence from systematic research."(9)
The questionnaire consisted of
| Visual analogue scales to determine the general practitioners' attitudes towards evidence based medicine | |
| Closed questions to assess their awareness of and perceived usefulness of extracting journals, review publications, and databases relevant to evidence based medicine; their ability to access Medline or other bibliographic databases and the world wide web; their understanding of technical terms; and their views on how best to move from opinion based practice to evidence based medicine | |
| A free text section to determine their views on the major barriers to practising evidence based medicine in general practice. These brief statements were coded and grouped by AMcC. (For details of the questionnaire, click here). |
We sent reminders to non-respondents in June and July 1997, and data on non-respondents were collected by AMcC from teaching and research networks and the 1997 Medical Directory.(10)
We entered the data into a spreadsheet. We initially identified 38 categories, but these were grouped into broader categories during the analysis. We analysed data from the visual analogue scales using spss for Windows 6.1.2 and analysed the other data using Microsoft Excel 5.0. We compared differences between respondents and non-respondents using the chi2 test.
Results
Of the 452 questionnaires we sent out, two were returned because the general practitioners had retired. We received 302 replies (67%) to the remaining 450 questionnaires. Table 1 compares the characteristics of the respondents and non-respondents.
Table 1 - Characteristics of 302 respondents* and 148
non-respondents to postal questionnaire of general practitioners in
former Wessex region. Values are numbers (percentages) of subjects
unless stated otherwise
| Respondents |
Non-respondents |
P
value of difference | Personal characteristics
| Men | 210/301
(70) | 103/141 (73)† | 0.48
| MRCGP | 183/298 (61) | 35/148
(24) | <0.0001 | Full time
principals | 242/300
(81) | Unavailable | Practice
characteristics | WReN member‡ | 41/302 (14)
| 5/148 (3) | <0.05 | Undergraduate
teaching practice | 185/297 (62) | 81/148
(55) | 0.13 | Postgraduate training
practice | 154/299
(52) | Unavailable | Practice size less
than 5000 | 61/299
(20) | Unavailable | Mean No of full time
equivalent partners
| 4.7 | Unavailable | Fundholding
practice | 165/298
(55) | Unavailable | Setting: | Rural | 56/300
(19) | Unavailable | Urban | 129/300
(43) | Unavailable | Mixed | 115/300
(38) | Unavailable | *Some respondents did not answer all the questions.
| †We were unable to determine the sex of some of the non-respondents. ‡Wessex Primary Care Research Network. | ||||||||||||||||||||||||
| Attitudes towards evidence based medicine - The figure shows
the responding general practitioners' attitudes towards evidence based
medicine. Most were welcoming towards the current promotion of evidence
based medicine (A), although colleagues were perceived to be less
welcoming (B), and most agreed that practising evidence based medicine
improved patient care (C) and that research findings were useful in the
day to day management of patients (D). The median value for the
estimated percentage of the respondents' clinical practice that was
evidence based was 50% (E). Awareness and perceived usefulness of relevant information sources - Table 2 shows that the doctors had a low level of awareness of extracting journals, review publications, and databases relevant to evidence based medicine. Only 40% of respondents were aware of the Cochrane Database of Systematic Reviews, 52% of Bandolier, and 60% of Effective Health Care Bulletins. |  | |
| Attitudes of 293 general practitioners towards evidence based medicine: (A) attitude towards current promotion of evidence based medicine (100=extremely welcoming, 0=extremely unwelcoming); (B) perceived attitude of colleagues towards evidence based medicine (100=extremely welcoming, 0=extremely unwelcoming); (C) practising evidence based medicine improved patient care (100=strongly agree, 0=strongly disagree); (D) perceived usefulness of evidence based medicine in day to day management of patients (100=extremely useful, 0=totally useless); (E) estimated percentage of respondent's clinical practice that is evidence based. Box plots show maximum and minimum values, median, and first and third quartiles. |
| Table 2 - Awareness of 302 general practitioners* of extracting journals, review publications, and databases relevant to evidence based medicine and their usefulness. Values are numbers (percentages) of subjects who ticked each response | ||||
| Publication | Unaware | Aware but not used | Read | Used to help in clinical decision making |
|---|---|---|---|---|
| Bandolier(published in Oxford) | 141/294 (48) | 49/294 (17) | 55/294 (19) | 49/294 (17) |
| Evidence-Based Medicine(BMJ publishing group) | 83/287 (29) | 132/287 (46) | 52/287 (18) | 20/287 (7) |
| Effective Health Care Bulletins(Universities of Leeds and York) | 115/287 (40) | 48/287 (17) | 81/287 (28) | 43/287 (15) |
| Cochrane Database of Systematic Reviews(part of Cochrane Library) | 169/284 (60) | 89/284 (31) | 15/284 (5) | 11/284 (4) |
| Database of Abstracts of Reviews of Effectiveness(part of Cochrane Library) | 231/283 (82) | 43/283 (15) | 7/283 (2) | 2/283 (1) |
| Evidence-Based Purchasing(South and West R&D) | 232/283 (82) | 36/283 (13) | 12/283 (4) | 3/283 (1) |
| *Some respondents did not answer all the questions. | ||||
Access to relevant databases and the world wide web - Only 20% (41/220) of respondents had access to Medline or other bibliographic databases at their surgery while 76% (173/227) had access at their local library and 21% (45/219) at their home. They also lacked access to the world wide web: only 17% (40/236) had access at their surgery, 41% (73/178) at their local library, and 29% (71/247) at their home. In the previous year 51% (102/201) had used Medline or another database for literature searching or had asked someone to do a search on their behalf, and 12 had searched on more than 10 occasions. Of these 102 doctors, 28 reported having had some training in literature searching, while a total of 16% (47/297) had received formal training in search strategies. At least 11 of those trained had not made a literature search in the previous year. Those trained in searching were more likely to have access to Medline or another database in their home (30% (14/47) versus 11% (27/250)) and in their surgery (32% (15/47) versus 12% (29/250)).
Understanding of technical terms used in evidence based medicine - Most of the respondents had some understanding of the technical terms used in evidence based medicine, and a third felt able to explain to others the meaning of some of these terms (table 3). However, only 15% (44/290) understood publication bias and could explain it to others. A considerable proportion who did not understand the terms expressed a desire to understand (9-48%). In total 39% (115/297) had received formal training in critical appraisal.
Table 3 - Understanding of 302 general practitioners* of
technical terms used in evidence based medicine. Values are numbers
(percentages) of subjects who ticked each response
| Term |
It would not be helpful for me to
understand |
Don't understand but would like to
|
Some understanding |
Understand and could
explain to others | Relative
risk | 7/291
(2) | 31/291 (11) | 157/291
(54) | 96/291 (33) | Absolute risk | 7/291
(2) | 40/291 (14) | 153/291
(53) | 91/291 (31) | Systematic
review | 8/288 (3) | 55/288
(19) | 160/288 (56) | 65/288 (23) | Odds
ratio | 27/289 (9) | 138/289
(48) | 92/289 (32) | 31/289 (11)
| Meta-analysis | 12/291 (4) | 63/291
(22) | 120/291 (41) | 96/291 (33) | Clinical
effectiveness | 5/290 (2) | 27/290
(9) | 165/290 (57) | 93/290 (32) | Number
needed to treat | 6/288 (2) | 54/288
(19) | 126/288 (44) | 102/288 (35)
| Confidence interval | 17/290 (6) | 90/290
(31) | 124/290 (43) | 59/290 (20)
| Heterogeneity | 20/289 (7) | 124/289
(43) | 116/289 (40) | 29/289 (10)
| Publication bias | 21/290 (7) | 88/290
(30) | 133/290 (46) | 44/290 (15) | *Some respondents did not answer all the questions. | | ||||||||
Views on major barriers to practising evidence based medicine - The main perceived barrier to practising evidence based medicine in general practice was a lack of personal time (table 4).
Table 4 - Perceived major barriers to practising
evidence based medicine in general practice reported by 242 general
practitioners*
| Perceived barrier | No of responses
| Lack of personal time | 171
| Context of primary care: | 62
| Personal and organisational
inertia | 35 | Morale in general
practice | 6 | Lack of investment by
health authorities and
trusts | 4 | Difficulties in
involving whole practice | 5 | No
financial gain in using evidence based
medicine | 8 | Closed
lists | 4 | The evidence
itself: | 59 | Lack of hard
evidence | 20 | Evidence not related
to context of primary care | 16 | Too
much evidence | 9 | Availability and
access to information | 14 | Attitudes
of patients: | 44 | Patients'
expectations | 23 | Patients
demanding ineffective
treatment | 11 | The need for lengthy
discussions with patients | 6 | An
ignorant media | 4 | General
practitioners themselves: | 35
| Attitudes of
colleagues | 29 | Lack of critical
appraisal skills | 2 | Evidence based
medicine seen as
threat | 4 | Others | 3 | *Only 80% of the 302 respondents answered these questions.
Respondents gave more than one answer. | | ||
Views on how best to move from opinion based to evidence based medicine - Most of the respondents (57%) thought that the most appropriate way to move from opinion based practice to evidence based medicine was "using evidence based guidelines or protocols developed by colleagues for use by others," while 37% thought it should be by "seeking and applying evidence based summaries" and only 5% by "identifying and appraising the primary literature or systematic reviews" (table 5).
Table 5 - Views of 302 general practitioners* on ways of
moving from opinion based practice to evidence based general practice.
Values are numbers (percentages)
| Method of moving towards evidence based
medicine |
Method currently using |
Method of
interest for future use |
Most appropriate method
| a) Learning the skills of evidence based
medicine | 84/297
(28) | 101/296 (34) | 15/281 (5) | b) Seeking
and applying evidence based summaries | 215/297
(72) | 229/296 (77) | 105/281 (37) | c) Using
evidence based practice guidelines or protocols | 249/297
(84) | 230/296 (78) | 161/281 (57)
| Doctors currently using method (a) - Learning the skills
of evidence based medicine | a) Learning the skills of evidence based
medicine | - | 62/84
(74) | 12/84 (14) | b) Seeking and applying evidence
based summaries | 67/84 (80) | 64/84
(76) | 28/84 (33) | c) Using evidence based practice
guidelines or protocols | 69/84
(82) | 64/84 (76) | 39/84 (46)
| Doctors currently using method (b) - Seeking and
applying evidence based summaries | a) Learning the skills of
evidence based medicine | 67/215
(31) | 82/215 (38) | 11/215 (5) | b)
Seeking and applying evidence based
summaries | - | 191/215
(89) | 96/215 (45) | c) Using evidence based practice
guidelines or protocols | 174/215
(81) | 170/215 (79) | 96/215 (45)
| Doctors currently using method (c) - Using evidence
based practice guidelines or protocols | a) Learning the skills of
evidence based medicine | 69/249
(28) | 82/249 (33) | 8/249 (3) | b)
Seeking and applying evidence based summaries | 174/249
(70) | 194/249 (78) | 80/249 (32) | c)
Using evidence based practice guidelines or
protocols | - | 200/249
(80) | 146/249 (59) | *Some respondents did not answer all the questions. In the
questionnaire, method (a) was described as "by learning the skills of
evidence-based medicine i.e. to identify and appraise the primary
literature or systematic reviews oneself"; method (b) was "by
seeking and applying evidence-based summaries, which give the clinical
'bottom line.' Such summaries may be obtained from abstracting
journals"; and method (c) was "by using evidence based practice
guidelines or protocols developed by colleagues for use by others."
Respondents were allowed more than one response when asked what methods
they were currently using and would be interested in using in the
future but only one response when asked which of these methods they
thought was most appropriate in general practice. | | |||||||||||||||
Discussion
Methodological issues
A response rate of 67% is a considerable achievement as
response rates to questionnaire surveys among general practitioners
are dropping.(11) Respondents were more likely to be members
of the Royal College of General Practitioners and the Wessex Primary
Care Research Network. Other questionnaire studies have suggested that
members of the royal college are more innovative(12) and
more "enthusiastic" to participate in quality
assessment(13) than non-members. The difference between the
respondents' attitude and their perception of their colleagues'
attitudes could be explained by a more positive attitude of respondents
towards evidence based medicine than non-respondents.
Our subjects were general practitioners rather than primary healthcare teams. Our narrow focus was partly due to the availability of an adequate sampling frame, but we are sending a similar questionnaire to practice nurses to widen our understanding of evidence based health care in primary care.
Interpretation of findings
Attitudes towards evidence based medicine - Although most of
the respondents agreed that practising evidence based medicine improved
patient care, the median value for the estimated percentage of their
clinical practice that was evidence based was 50%. However, this was a
self reported question, and it had limitations. This estimate was
considerably less than one from a retrospective review of case notes,
which concluded that over 80% of interventions in general practice
were evidence based.(6) The methods used were criticised, as
the quality of evidence was not reviewed and non-experimental evidence
was included.(14,15) The case notes may not have been
representative of typical consultations, as only recorded consultations
with a primary diagnosis and intervention were used and in general
practice patients rarely enter the consulting room with a discrete, one
dimensional problem.(15,16) Other reviews have suggested
that evidence based medicine is less relevant to general practice than
other specialties because it mainly addresses the biomedical
perspective of diagnosis from a doctor centred
paradigm(7) and does not integrate quantitative and
qualitative research, epidemiology, and psychology and the skills of
public health and family medicine.(17)
Awareness of relevant information sources - Respondents showed a low level of awareness of extracting journals, review publications, and databases relevant to evidence based medicine. Attempts have been made to find out who uses the Cochrane Database(18) and whether obstetricians and gynaecologists were aware of and used it,(19) but there have been no such studies of general practitioners. The practice of evidence based medicine involves integrating individual clinical expertise with the best available external clinical evidence from systematic research.(9) Much of this clinical evidence in primary care has already been identified, critically appraised, and packaged in extracting journals and databases.(2)
Health authorities in Wessex send Effective Health Care Bulletins to every general practice, and Bandolier and Evidence-Based Purchasing are available to general practitioners on request without charge. Respondents may not have been aware of the formal title of some of these publications despite having read them and so we may have underestimated awareness. Of the general practitioners who were aware of these sources, 13-46% did not use them. Further studies with interviews are needed to understand why this is so. Without current best evidence, medical practice risks becoming out of date, to the detriment of patients.(9)
Access to relevant databases and the world wide
web - Less than a fifth of the respondents had access to
a r Understanding of technical terms - Our respondents
showed a partial understanding of the technical terms used in evidence
based medicine. Interpretation of evidence is a key element in
practising evidence based medicine, and this partial understanding
could hinder interpretation and make cascading of evidence to other
members of the primary care team more difficult.
Views on major barriers to practising evidence based
medicine - The barriers described in this study are more
pragmatic than some of those identified in other
papers.(7)(17) Lack of personal time was the main perceived
barrier. There are ways of increasing the time available for practising
evidence based medicine.(2)(20) This time could be spent
more efficiently by changing the emphasis of postgraduate education
away from lectures and toward training in accessing and interpreting
evidence and then spending time putting these skills into practice. Two
general practitioners in a Southampton pilot project receive
postgraduate education payments for preparing summaries of evidence
based medicine for their practices. Dawes suggested that a general
practitioner who spent an hour a week searching and reading would
make huge strides in implementing evidence.(2)
A considerable proportion of respondents perceived personal and
organisational inertia and the attitudes of colleagues as a major
barrier. Tensions between doctors in general practices may lead to
difficulties in investing in technology to access evidence and in
failures to agree practice policies on clinical management that are
evidence based. However, the attitudes of patients were also seen as a
barrier.
Views on how best to move to evidence based
medicine - The focus of workshops on critical appraisal and
evidence based medicine in Wessex has been on training healthcare
workers to identify and appraise primary literature or systematic
reviews. However, few respondents thought that this was the most
appropriate way to move from opinion based to evidence based medicine.
Most thought that the best way was by using evidence based guidelines
or protocols developed by colleagues for use by others. Only 14% of
those currently identifying and appraising primary literature or
systematic reviews thought this was the best method.
Conclusions
We thank the Wessex general practitioners who took part in this
survey.
Contributors: HS developed the original idea and questionnaire.
AMcC, HS, PW, and JF refined the questionnaire and jointly wrote the
paper. Chris Spencer-Jones, Paul Roderick, and Ruairidh Milne gave
advice on the questionnaire. AMcC coordinated the distribution and
follow up of the questionnaire, coded the free text sections, and
performed the data analysis. Wendy Davis coded the rest of the
questionnaire and provided administrative support. Mark Mullee advised
on the random sampling. AMcC is guarantor for the paper.
Funding: The Wessex Primary Care Research Network is funded by
the South and West Research and Development Directorate. The
Southampton GP Tutor Educational Fund paid for the coding and entry of
data.
Conflict of interest: None.
(Accepted 28 November 1997) Wessex Primary Care Research Network, Nightingale Surgery, Primary Medical Care,
Correspondence to: Dr
Alastair McColl
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Postgraduate tutors, health authorities, and primary care research
networks are attempting to encourage general practitioners to implement
evidence based general practice. They should refocus their efforts on
promoting and improving access to summaries of evidence. They should
also encourage local general practitioners working in localities or
commissioning groups, who are themselves skilled in accessing and
interpreting evidence, to develop local evidence based guidelines and
advice. This may be a more effective approach to harness the interest
and welcoming attitude of general practitioners towards evidence based
medicine than trying to teach all general practitioners skills in
search and critical appraisal.
Key Messages
Despite considerable variation in 302 general practitioners'
attitudes to the promotion of evidence based medicine, most were
welcoming and agreed that it improved patient care
There was a low level of awareness of extracting
journals, review publications, and databases relevant to evidence based
medicine, and the major perceived barrier to its practice was lack of
personal time
In their surgery only 20% of general practitioners had access
to Medline or other bibliographic databases and 17% had access to the
world wide web
Most had some understanding of the technical terms used in
evidence based medicine, but less than a third felt able to explain to
others the meaning of these terms
Respondents thought that the best way to move from opinion
based practice towards evidence based medicine was by using evidence
based guidelines or protocols developed by colleagues
Views on how best to move from opinion based to evidence based
medicine.
Primary
Medical Care,
University of Southampton,
Aldermoor Health Centre,
Southampton SO16 5ST
Alastair
McColl, lecturer in public health medicine
Helen Smith, senior lecturer in primary care
Great Well Drive,
Romsey,
Hampshire SO51 7QN
Peter White,
general practitioner tutor
University of Southampton
Jenny Field,
senior lecturer in primary care
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