BMJ 1999;318:1532-1535 ( 5 June )

Information in practice

General practitioners' perceptions of effective health care

Zelda Tomlin, research fellow,  Charlotte Humphrey, senior lecturer in sociology,  Stephen Rogers, senior lecturer in primary health care. 

Department of Primary Care and Population Sciences, Royal Free and University College Medical School, University College London, London NW3 2PF

Correspondence to: Dr Humphrey charlot{at}rfhom.ac.uk

Objectives: To explore general practitioners' perceptions of effective health care and its application in their own practice; to examine how these perceptions relate to assumptions about clinicians' values and behaviour implicit in the evidence based medicine approach.
Design: A qualitative study using semistructured interviews.
Setting: Eight general practices in North Thames region that were part of the Medical Research Council General Practice Research Framework.
Participants: 24 general practitioners, three from each practice.
Main outcome measures: Respondents' definitions of effective health care, reasons for not practising effectively according to their own criteria, sources of information used to answer clinical questions about patients, reasons for making changes in clinical practice.
Results: Three categories of definitions emerged: clinical, patient related, and resource related. Patient factors were the main reason given for not practising effectively; others were lack of time, doctors' lack of knowledge and skills, lack of resources, and "human failings." Main sources of information used in situations of clinical uncertainty were general practitioner partners and hospital doctors. Contact with hospital doctors and observation of hospital practice were just as likely as information from medical and scientific literature to bring about changes in clinical practice.
Conclusions: The findings suggest that the central assumptions of the evidence based medicine paradigm may not be shared by many general practitioners, making its application in general practice problematic. The promotion of effective care in general practice requires a broader vision and a more pragmatic approach which takes account of practitioners' concerns and is compatible with the complex nature of their work.

Key messages Evidence based medicine has emerged as a new paradigm to prevent inappropriate variations in clinical practice This study explored the extent to which evidence based medicine's emphasis on clinical effectiveness, self analysis, and information seeking is congruent with the modes of thinking and behaviour of general practitioners General practitioners' definitions of effective health care fell into three categories of clinical, patient related, and resource related; their main reason for not practising effectively was patient factors, and others were lack of time, lack of knowledge and skills, lack of resources, and "human failings"; and their main sources of information in cases of clinical uncertainty were general practitioner partners and hospital doctors The central assumptions of the evidence based medicine paradigm may not be shared by many general practitioners, making its application in general practice problematic Promotion of effective care in general practice requires a broader vision and a more pragmatic approach that takes account of practitioners' concerns and is compatible with the complex nature of their work

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