BMJ 2001;323:1100-1102 ( 10 November )

Primary care

Why general practitioners do not implement evidence: qualitative study

A C Freeman, general practice research facilitator, K Sweeney, general practice research facilitator. 

Somerset and North and East Devon Primary Care Research Network, Institute of General Practice, School of Postgraduate Medicine and Health Sciences, Exeter EX2 5DW

Correspondence to: A C Freeman PCRN{at}exeter.ac.uk


    Abstract
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

Objectives: To explore the reasons why general practitioners do not always implement best evidence.
Design: Qualitative study using Balint-style groups.
Setting: Primary care.
Participants: 19 general practitioners.
Main outcome measures: Identifiable themes that indicate barriers to implementation.
Results: Six main themes were identified that affected the implementation process: the personal and professional experiences of the general practitioners; the patient-doctor relationship; a perceived tension between primary and secondary care; general practitioners' feelings about their patients and the evidence; and logistical problems. Doctors are aware that their choice of words with patients can affect patients' decisions and whether evidence is implemented.
Conclusions: General practitioner participants seem to act as a conduit within the consultation and regard clinical evidence as a square peg to fit in the round hole of the patient's life. The process of implementation is complex, fluid, and adaptive.


What is already known on this topic
General practitioners do not always act on evidence in clinical practice

General practitioners are reluctant to jeopardise their relationship with the patient and sometimes feel that patients are unwilling to take drugs

What this study adds
Implementation of evidence by general practitioners is a complex and fluid process

Decisions are influenced by the doctor's personal and professional experience as well as by their knowledge of and relationship with the patient

Doctors' choice of words can influence patients' decisions about treatment



    Introduction
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

Although evidence based medicine has heightened awareness of the most effective management strategies for many conditions, much of the evidence is not acted on in everyday clinical practice.1 Numerous strategies to improve implementation of such evidence have been tested,2 and various impediments have been identified.3 General practitioners have been cautious about the evidence based model generally.4 Reasons for this include being reluctant to jeopardise relationships with the patient,5 and patients' unwillingness to take certain drugs.6

There may be unique barriers to implementing evidence in general practice within a patient centred context.7 We used a qualitative approach to explore the reasons why and circumstances in which doctors had not implemented evidence they knew about.


    Participants and methods
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

Three focus groups of established general practitioners were set up in three areas, each located around a different district general hospital in the south west of England. Each area is geographically separate by about 80 km and tends to develop its own medical community.

Participants were asked to discuss their behaviour in individual cases, which could be seen as sensitive. We therefore adapted the standard focus group techniques to use a Balint-style model. 8 9 The particular Balint-style feature of these groups that distinguished them from standard focus groups was that each meeting focused around the case notes of a particular patient, the doctor-patient relationship, and the feelings that were generated.

The groups consisted of six to eight volunteer general practitioners, each led by an experienced group leader. Participating doctors represented a mix of urban, rural, and semirural practices. There were a total of 19 doctors: 13 men and six women.

At each meeting, a group member was asked to present the details of a case in which he or she had knowingly not followed evidence based practice. We asked the groups to discuss the case and explore the implementation issues arising from it as well as the doctor's feelings about these issues. The local research ethics committee approved the study. The researchers were not part of the group, but before the first meeting of each group a researcher attended and explained the research agenda.

The meetings were taped and transcribed, and each researcher separately analysed the transcripts. Each researcher used a grounded theory approach in developing theoretical principles (or at least explanatory principles).10 We met to compare analysis and identify common themes. To ensure compatibility of analysis, we each analysed three transcripts jointly and the others separately.


    Results
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

Transcripts for 11 meetings were available for analysis. The main clinical areas the general practitioners discussed included hypertension, ischaemic heart disease, and anticoagulation. Six main themes emerged from the data (box).


Main themes from data

The process of implementing clinical evidence is affected by the personal and professional experiences of the doctor

The relationship that the doctor has with individual patients also affects the process

There is a perceived tension between primary and secondary care: the doctors thought that specialists approach evidence based practice differently

The practitioner's feelings about their relationships with patients and about the evidence have an important role in modifying how clinical evidence is applied

The doctor's choice of words in consultations can sway patients to accept or reject clinical evidence. Doctors realise this and can use it to pre-empt patients' decisions

Implementation comes up against logistical problems, which affect how evidence is applied

Personal and professional experience of practitioner
Despite being a relatively homogeneous group, the general practitioners' enthusiasm for the evidence and the way in which they implemented it varied. This seemed to be partly explained by their previous experience of clinical practice. Mishaps or spectacular clinical successes can have a direct influence on subsequent practice.

Two influences were relevant: the doctors' life experience and experience of hospital medicine as students or juniors doctors. "My grandfather died when he was shocked," recalled one participant, discussing anticoagulation in atrial fibrillation, "so I reach for a decent dose of warfarin and digoxin no hesitation at all." Another said: "I actually had two 50 year olds who had strokes from atrial fibrillation because they didn't get warfarin . . . that really hit me." In another group, one general practitioner said, " I lost a patient as an SHO, so that puts me off warfarin."

Doctor's relationship with individual patients
Implementation was influenced by the relationships that doctors developed with their patients. "Even if the evidence was extremely good," one general practitioner said, "most of us would only ever interpret it in the context of the patient." Perceived patient characteristics could have a positive or negative effect on implementation.

Patients could influence clinical decisions as a result of their own experiences. One patient reportedly said, "My brother died on warfarin, I'm not taking rat poison." Some doctors found that personal relationships tended to make practising evidence based medicine "harder because you have a close relationship with them." At other times patients could simply block a doctor's attempts to practise evidence based medicine: "Sod that, says the patient, I'm fine."

The assumptions doctors made about their patients seemed at times paternalistic. Some were described by their doctor as " the type who did not want to rock the boat," others as "depressive cum fatalist." "Somatisers," declared one doctor, "eventually get something." By using these descriptions, the contributors were suggesting that their view of the patient modified how and when they applied the evidence.

Perceived tension between primary and secondary care
The general practitioners felt that secondary care doctors approached evidence based practice differently, treating "diseases rather than patients" in a context that they perceived as much more controlled than the "real life" of general practice. On the whole, the relationship was described in pejorative terms. One doctor described cardiologists as "being a bit of an evidence based mafia."

Specialists were accused of failing to realise just how tricky it was controlling some common diseases. "You get stroppy letters from the clinic saying your patient's blood pressure is still 160, and I go . . . yes, yes, I know. You feel under pressure from the guidelines, but you know it's not from want of trying." In one group, quite a fundamental difference in approach to clinical practice between primary and secondary care was described. "A few hypertensives, without any symptoms, they're well. They're just running a risk. We give them a drug and a side effect---change the quality of their life," said one doctor.

Clinical evidence can evoke feelings among doctors and patients
For the doctors in our study, clinical evidence is not just an intellectually celibate commodity that is lifted out of medical journals and transferred to a patient. It has an emotional impact on practitioners and patients. "Yes it does make me feel anxious . . . all the BMJs, all the rags . . . these people must be on warfarin." " With me messing about with his medication and trying to practise evidence based medicine, I found it was making [the patient] feel more anxious."

Another aspect of this theme reflected the doctors' feelings about the consequences of failing to act on clinical evidence. One participant poignantly described how, after the death of a young man who had been inadequately anticoagulated for a venous thrombosis, he felt unease "standing behind his widow in the greengrocer queue."

The group discussions also produced data that indicated doctors' familiarity with the evidence and a positive attitude to it. They described its importance to everyday practice: "I think it's always the basis for most of what I do . . . it's fundamentally evidence based but it's tailored completely." They recognised that evidence based medicine gives new emphasis: "That is the one that I have been hammering, the diabetic blood pressures, to try and get them to 140/80, and I am certainly getting them better than I was but it is hard work." For some of the general practitioners evidence based medicine was revolutionary: "I think that is the first time I have become aware of one study, or group of studies, that has actually changed my practice within a week."

Words used by doctors can influence patients' decisions
Doctors realised that the words they chose to present the evidence could have a strong influence on the patient's decision. They effectively limited the options while seeming to invite the patient to make the decision. The semantics then affect the way in which evidence is implemented by swaying the patient in a particular direction. "There is a reasonable chance of you having a stroke in the next year or so if you don't do something about your blood pressure . . . I'm as barbaric as that," commented one participant.

The tension between encouraging autonomy and effectively limiting options by the slanted presentation of relevant material was a relatively strong theme: "I make these judgments in theory with the patient but probably on my own."

The choice of words or the use of metaphors like "slanting" or "selling" were mechanisms the doctors used to influence patients to make a decision about their treatment that was consistent with what the doctor had decided was appropriate. Doctors would refer to "rat poison" when describing warfarin if they felt its use would be difficult or inappropriate, or describe pills as "having been shown to keep the heart young" when they wanted a patient to agree to treatment.

Logistics of general practice
The doctors in this study described some tricky logistical problems that made them less enthusiastic about implementing clinical evidence. "Risky," "hard work," and a "hassle" both for doctors and patients were typical descriptions of the problems of starting treatment. One doctor said, "The problem is starting him on the ACE because he is very anxious about any medication change, and every time you change the medication it entails another four or five visits to go and see him and to try and reassure him that he is on the right medication."

Knowing the patient's personal situation influenced implementation too. Doctors took into account the patient's behaviour, capabilities, or rural location when making decisions. One doctor felt reluctant to anticoagulate one 88 year old woman because "she had an alcohol problem, kept falling. She was forever in casualty being stitched up, bandaged up, whatever."


    Discussion
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

The themes emerging from our study show the complexity of implementing evidence from well structured clinical trials in individual patients. Our findings are supported by other studies in the United Kingdom, 6 11 the Netherlands,5 and Australia.12 In some ways, our study illustrates what Kernick has described as the parallel universes of scientific research and general practice.13 The doctors in this study were exploring personal importance---that is, the "key to the transfer of an idea to and the evaluation and interpretation of an idea by the doctor and patient together."14 Evidence is not implemented in a simple linear way, as some definitions of evidence based practice imply, but in an evolving process whereby reciprocal contributions from the doctor and the patient over time influence how evidence ultimately is used.

Doctors in the groups were talking about situations in which they already knew the evidence but had not implemented it. Although the groups did not confine their discussion exclusively to incidents in which the clinical evidence was not applied, the data focus wholly on implementation issues. We felt that if a wider brief had been given to the groups---for example, to discuss implementation generally---the detail of the difficulties these practitioners had implementing evidence would have been less likely to come up. There was plenty of evidence that the doctors were implementing evidence and were happy to do so.

The data also indicated that doctors were working together with patients and for the benefit of their patients. Sometimes these factors and the doctor's experience lead to the conclusion that strictly sticking to the rules of guidelines is not appropriate. Whether that is the strength of individual doctoring in a long standing and trusting relationship with a patient or a weakness remains open to debate.

    Acknowledgments

We thank the general practitioners who gave their time to help in this research.

Contributors: see bmj.com

    Footnotes

Funding: This research was supported by a grant from the NHS South West Research and Development Executive.

Competing interests: None declared.

The full version of this article appears on bmj.com


    References
Top
Abstract
Introduction
Participants and methods
Results
Discussion
References

1. Haynes RB, Sackett D, Guyatt G, Cook D. Transferring evidence from research to practice: overcoming barriers to application. Evidenced-Based Medicine 1997; 2: 68-69.
2. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J 1995; 153: 1423-1431.
3. Budd J, Dawson S. Influencing clinical practice: implementation of research and development results. London: Management School, Imperial College of Science Technology and Medicine, 1994. (Report to North Thames Regional Health Authority.)
4. Sweeney KG. Evidence an uncertainty. In: Marinker M, ed. Sense and sensibility in health care. London: BMJ Publishing, 1996:59-87.
5. Veldhuis M, Wigersma L, Okkes I. Deliberate departures from good general practice: a study of motives among Dutch general practitioners. Br J Gen Pract 1998; 48: 1833-1836[Medline].
6. Howitt A, Armstrong D. Implementing evidence based medicine in general practice: audit and qualitative study of antithrombotic treatment for atrial fibrillation. BMJ 1999; 318: 1324-1327[Abstract/Full Text].
7. McColl A, Smith H, White P, Field J. General practitioner's perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998; 316: 361-365[Abstract/Full Text].
8. Balint M. The doctor, his patient and the illness. London: Pitman, 1957.
9. Salinsky J. Psychoanalysis and general practice: what did the Romans do for us? Br J Gen Pract 2001; 51: 506.
10. Glaser B, Strauss A. The discovery of grounded theory. Chicago: Aldine, 1957.
11. Tomlin Z, Humphrey C, Rogers S. General practitioners' perceptions of effective health care. BMJ 1999; 318: 1532-1535[Abstract/Full Text].
12. Mayer J, Piterman L. The attitudes of Australian GPs to evidence-based medicine: a focus group study. Fam Pract 1999; 16: 627-632[Medline].
13. Kernick DP. Muddling through in a parallel track universe [letter]. Br J Gen Pract 2000; 50: 325[Medline].
14. Sweeney KG, MacAuley D, Gray DP. Personal significance: the third dimension. Lancet 1998; 351: 134-136[Medline].

(Accepted 6 August 2001)

© BMJ 2001
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

Personal knowledge
Kieran Sweeney
BMJ 2006 332: 129-130. [Extract] [Full Text] [PDF]

Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis
Niteesh K Choudhry, Geoffrey M Anderson, Andreas Laupacis, Dennis Ross-Degnan, Sharon-Lise T Normand, and Stephen B Soumerai
BMJ 2006 332: 141-145. [Abstract] [Full Text] [PDF]

Doctors and managers
Hugo Mascie-Taylor, Tim Wilson, Kieran Sweeney, Mayur Lakhani, Thomas Plochg, Kiki Lombarts, Yolande Witman, Niek Klazinga, and Karen Kruijthof
BMJ 2003 326: 656. [Extract] [Full Text] [PDF]

Why general practitioners do not implement evidence
John Temple, Simon de Lusignan, Sally Wells, and Andrew Singleton
BMJ 2002 324: 674. [Extract] [Full Text]

The agonies of evidence
BMJ 2001 323: 0. [Full Text] [PDF]

Personal and patient feelings affect how GPs apply clinical evidence
BMJ 2001 323: 0. [Full Text]

This article has been cited by other articles:

  • Lewis, P. J, Tully, M. P (2009). Uncomfortable prescribing decisions in hospitals: the impact of teamwork. JRSM 102: 481-488 [Abstract] [Full text]  
  • Corbett, M., Foster, N., Ong, B. N. (2009). GP attitudes and self-reported behaviour in primary care consultations for low back pain. Fam Pract 26: 359-364 [Abstract] [Full text]  
  • Beaulieu, M.-D., Proulx, M., Jobin, G., Kugler, M., Gossard, F., Denis, J.-L., Larouche, D. (2008). When Is Knowledge Ripe for Primary Care?: An Exploratory Study on the Meaning of Evidence. Eval Health Prof 31: 22-42 [Abstract]  
  • Kunz, R, Wegscheider, K, Guyatt, G, Zielinski, W, Rakowsky, N, Donner-Banzhoff, N, Muller-Lissner, S (2007). Impact of short evidence summaries in discharge letters on adherence of practitioners to discharge medication. A cluster-randomised controlled trial. Qual Saf Health Care 16: 456-461 [Abstract] [Full text]  
  • James, E. L., Fraser, C., Anderson, K., Judd, F. (2007). Use of research by the Australian health promotion workforce. Health Educ Res 22: 576-587 [Abstract] [Full text]  
  • Harris, M, Smith, B J, Veale, A, Esterman, A, Frith, P A, Selim, P (2006). Providing patients with reviews of evidence about COPD treatments: a controlled trial of outcomes. Chronic Respiratory Disease 3: 133-140 [Abstract]  
  • Tully, M. P., Cantrill, J. A. (2006). The validity of explicit indicators of prescribing appropriateness. Int J Qual Health Care 18: 87-94 [Abstract] [Full text]  
  • Sweeney, K. (2006). Personal knowledge. BMJ 332: 129-130 [Full text]  
  • Choudhry, N. K, Anderson, G. M, Laupacis, A., Ross-Degnan, D., Normand, S.-L. T, Soumerai, S. B (2006). Impact of adverse events on prescribing warfarin in patients with atrial fibrillation: matched pair analysis. BMJ 332: 141-145 [Abstract] [Full text]  
  • Burkiewicz, J. S, Zgarrick, D. P (2005). Evidence-Based Practice by Pharmacists: Utilization and Barriers. The Annals of Pharmacotherapy 39: 1214-1219 [Abstract] [Full text]  
  • Walker, J., Mathers, N. (2004). Working together: a qualitative study of effective group formation amongst GPs during a cost-driven prescribing initiative. Fam Pract 21: 552-558 [Abstract] [Full text]  
  • Schunemann, H. J., Cook, D., Grimshaw, J., Liberati, A., Heffner, J., Tapson, V., Guyatt, G. (2004). Antithrombotic and Thrombolytic Therapy: From Evidence to Application: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126: 688S-696S [Abstract] [Full text]  
  • Lipman, T., Murtagh, M. J, Thomson, R. (2004). How research-conscious GPs make decisions about anticoagulation in patients with atrial fibrillation: a qualitative study. Fam Pract 21: 290-298 [Abstract] [Full text]  
  • Bindels, R., Hasman, A., Derickx, M., van Wersch, J. W. J., Winkens, R. A. G. (2003). User satisfaction with a real-time automated feedback system for general practitioners: a quantitative and qualitative study. Int J Qual Health Care 15: 501-508 [Abstract] [Full text]  
  • Jette, D. U, Bacon, K., Batty, C., Carlson, M., Ferland, A., Hemingway, R. D, Hill, J. C, Ogilvie, L., Volk, D. (2003). Evidence-Based Practice: Beliefs, Attitudes, Knowledge, and Behaviors of Physical Therapists. ptjournal 83: 786-805 [Abstract] [Full text]  
  • Getz, L., Sigurdsson, J. A, Hetlevik, I. (2003). Is opportunistic disease prevention in the consultation ethically justifiable?. BMJ 327: 498-500 [Full text]  
  • de Lusignan, S. (2003). What Is Primary Care Informatics?. J. Am. Med. Inform. Assoc. 10: 304-309 [Abstract] [Full text]  
  • Jacobson, L., Elwyn, G., Robling, M., Jones, R. T. (2003). Error and safety in primary care: no clear boundaries. Fam Pract 20: 237-241 [Abstract] [Full text]  
  • Gray, D. P., Evans, P., Sweeney, K., Lings, P., Seamark, D., Seamark, C., Dixon, M., Bradley, N. (2003). Towards a theory of continuity of care. JRSM 96: 160-166 [Full text]  
  • DeWilde, S, Carey, I M, Bremner, S A, Richards, N, Hilton, S R, Cook, D G (2003). Evolution of statin prescribing 1994-2001: a case of agism but not of sexism?. Heart 89: 417-421 [Abstract] [Full text]  
  • Mascie-Taylor, H., Wilson, T., Sweeney, K., Lakhani, M., Plochg, T., Lombarts, K., Witman, Y., Klazinga, N., Kruijthof, K. (2003). Doctors and managers. BMJ 326: 656-656 [Full text]  
  • Rousseau, N., McColl, E., Newton, J., Grimshaw, J., Eccles, M. (2003). Practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care. BMJ 326: 314-314 [Abstract] [Full text]  
  • Prosser, H., Almond, S., Walley, T. (2003). Influences on GPs' decision to prescribe new drugs--the importance of who says what. Fam Pract 20: 61-68 [Abstract] [Full text]  
  • Fuat, A., Hungin, A P. S, Murphy, J. J. (2003). Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 326: 196-196 [Abstract] [Full text]  
  • Decramer, M., Roussos, C. (2003). Early detection: introduction. Eur Respir J 21: 1S-2s [Full text]  
  • Partridge, M.R. (2003). Translating research into practice: how are guidelines implemented?. Eur Respir J 21: 23S-29s [Abstract] [Full text]  
  • Green, R., Kwok, S., Durrington, P.N. (2002). Preventing cardiovascular disease in hypertension: effects of lowering blood pressure and cholesterol. QJM 95: 821-826 [Abstract] [Full text]  
  • Ghosh, A. K., Huang, E. S., Stafford, R. S. (2002). Adherence to Evidence-Based Therapy: Some Practical Problems. Arch Intern Med 162: 1310-1311 [Full text]  
  • Haynes, R B., Devereaux, P J, Guyatt, G. H (2002). Physicians' and patients' choices in evidence based practice. BMJ 324: 1350-1350 [Full text]  
  • Nissen, M., Del Mar, C. (2002). GPs should reduce antibiotic use with alternative treatments. BMJ 324: 1099-1099 [Full text]  
  • Ely, J. W, Osheroff, J. A, Ebell, M. H, Chambliss, M L., Vinson, D. C, Stevermer, J. J, Pifer, E. A (2002). Obstacles to answering doctors' questions about patient care with evidence: qualitative study. BMJ 324: 710-710 [Abstract] [Full text]  
  • Temple, J., de Lusignan, S., Wells, S., Singleton, A. (2002). Why general practitioners do not implement evidence. BMJ 324: 674-674 [Full text]  
  • (2002). Will That Study Change Your Practice?. JWatch Emergency Med. 2002: 10-10 [Full text]  

Rapid Responses:

Read all Rapid Responses

The complex relation between GPs and evidence.
Sergio Stagnaro
bmj.com, 9 Nov 2001 [Full text]
It appears evidence based practice is a skill that must be taught.
Stephen Workman
bmj.com, 9 Nov 2001 [Full text]
best practice is best in general practice
Paul McDonald
bmj.com, 10 Nov 2001 [Full text]
"Old habits"
Peter Lake
bmj.com, 10 Nov 2001 [Full text]
Better communication helps
Kyle Perrin
bmj.com, 11 Nov 2001 [Full text]
Noncompliance may be justifiable
Joseph Watine
bmj.com, 12 Nov 2001 [Full text]
Making evidence easy for general practitioners: Rule 3-30
Enrique Sánchez-Delgado
bmj.com, 12 Nov 2001 [Full text]
Re: Making evidence easy for general practitioners: Rule 3-30
D A Fitzmaurice
bmj.com, 14 Nov 2001 [Full text]
Implementing evidence in general practice
Derek Mitchell
bmj.com, 16 Nov 2001 [Full text]
Knowledge Management, a balanced approach.
Sally Wells
bmj.com, 21 Nov 2001 [Full text]
Why GPs do not apply evidence: the importance of identifying barriers and facilitators
Chris Salisbury
bmj.com, 22 Nov 2001 [Full text]
Re: Implementing evidence in general practice
David Syme
bmj.com, 23 Nov 2001 [Full text]
Evidence is slippery stuff
John Temple
bmj.com, 26 Nov 2001 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ