Introduction

Top Abstract Introduction Participants and methods Results Discussion References

The concept of effectiveness has come to dominate the healthcare debate. The emergence of evidence of variations in practice, with accompanying doubts on the clinical effectiveness of some of those practices, ^{1 2} has shown the need for a fundamental questioning of the way in which clinical decisions are made, identifying the reasons for such variation, and finding ways of addressing inappropriate variations. ^{3 4}

Awareness of the latest scientific evidence and the ability to critically appraise and assess the applicability of this evidence have been identified as crucial ingredients that are missing in everyday medical practice, and evidence based medicine has emerged as a new paradigm.⁵ Evidence based medicine is defined as the "conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."⁶ This approach is underpinned by the assumption that practitioners regard clinical effectiveness as a priority and will be keen to act in a way that optimises thisthat is, to question their clinical practice systematically and, where shortcomings are identified, change that practice in line with scientifically valid evidence.

Our research, carried out in general practice, explores the extent to which this emphasis on clinical effectiveness, self analysis, and information seeking is congruent with the modes of thinking and behaviour of a service general practitioner. We asked doctors to describe how they defined effectiveness in health care, whether they thought they always practised effectively and, if not, why not. We also asked them how they sought answers to clinical questions about individual patients and about recent changes in their own clinical practice and how these had come about.

	Participants and methods

Top Abstract Introduction Participants and methods Results Discussion References

The study was carried out in the summer of 1997 at eight practices in the North Thames region that were members of the Medical Research Council General Practice Research Framework, a network of about 900 practices that have expressed a willingness to participate in MRC research projects.⁷ Framework practices are reimbursed for the time that practice nurses spend on the projects, have lockable filing facilities, and out of hours surgeries for study patients. The practices were recruited from those that responded to an invitation to participate in a feasibility study for a randomised controlled trial of implementation strategies to promote use of evidence based guidelines.

The data presented in this paper were collected as part of baseline interviews for the feasibility study, which were undertaken with 24 doctors, three from each practice. For each practice, those interviewed included at least one general practitioner with close links with the MRC, one woman general practitioner, and one general practitioner who was sceptical about joining the study, as identified during preliminary meetings. The interviews were semistructured and lasted about an hour. As well as the issues reported here, the interview covered the general practitioners' views on implementing research findings in clinical practice, practice guidelines and quality in health care, the characteristics of their practices, and their expectations of the feasibility study.

All the interviews were undertaken by the same researcher and were audio taped and subsequently transcribed. The transcripts were read to identify themes from individual responses, and these were then grouped into categories to produce typologies. To ensure reliability, two researchers analysed the data independently and the results were compared. Both generated similar systems of categorisation, although these were initially described in slightly different terms.

	Results

Top Abstract Introduction Participants and methods Results Discussion References

All 24 respondents were general practitioner principals, and 10 were women. Their mean age was 43 (range 29-61). The eight practices had between three and eight partners, all but one were fundholding, and two were training practices.

Definitions
Responses to the question on how general practitioners defined effective health care fell into three broad categories: clinical, patient related, and resource related. Just over half the respondents (13) offered more than one type of definition.

Clinical definitions
Most of the respondents (18) offered definitions that were centred around appropriate investigation, treatment, referral, and follow up; improving morbidity and mortality; and curing and preventing disease. The definitions in this category included two distinct groups: firstly, definitions that were strictly focused on diseasesuch as, "We ought to be able to see that the disease process is treated"and, secondly, definitions that incorporated a sense of the patientsuch as, "That the patient has got better from whatever it was or that you've alleviated the suffering in some way."

Patient related definitions
Just under half the respondents (10) offered definitions that were more patient oriented. The most common theme was educating patients and giving them relevant information so that they were able to participate in the decision making process. For example, effectiveness was defined as "helping [patients] to come to a level of understanding such that they can personally make the decision about what happens to them." Three respondents referred to patient satisfaction as a condition of effectiveness. Another theme, offered by one respondent, was temporarily acquiescing to patients' expectations in order to secure compliance: "You might give somebody a big dose of something to make them better quickly so that they then believe you later when you want to change things."

Resource related definitions
Eight respondents gave definitions related to resources. These included ideas about cost effective care for individual patients and about a population perspectivefor example: "All our decision making before used to be [that] a patient would come to you, and you just made a decision on the basis of that patient, but now I think there is a need for it to be made in a wider context."

Reasons for not practising effectively
Only one respondent thought he always practised effectively. The rest admitted departing from their own models of effective health care in everyday practice. Four categories of reasons for this emerged, with 15 respondents citing more than one category.

Doctor related reasons
Fourteen respondents mentioned factors that originated from the doctor, either as a professional or as an individual. Nine respondents cited self perceived shortcomings in knowledge, experience, and skills and how well these were applied in practicefor example: "I don't pretend to be up to date all the time" and "Pressure from conflicting ideas so that you don't really know if you are right or wrong." In addition, feelings of being tired, stressed, or unmotivated (what one doctor called "human failings") were referred to by five respondents"[In] periods when I've been under enormous personal stress ... my referral patterns shoot up."

Patient related reasons
Seven respondents mentioned factors that emanated from patients. It was suggested that when patients presented with more than one problem, sometimes acknowledged and sometimes hidden, it was necessary to prioritise even if this meant ignoring some of the problems. One example given was that of an overweight smoker who had had a heart attack; the general practitioner thought that the smoking should be tackled first and the obesity left for later consideration. Alternatively, the effective treatment of one condition might exacerbate the symptoms of another. The example was given of a patient with severe coronary artery disease, gastrointestinal disease, and severe osteoarthritis, for whom appropriate treatment of the osteoarthritis with non-steroidal anti-inflammatory drugs might exacerbate the gastrointestinal problems. Two respondents also mentioned patients' non-compliance as an obstacle to practising effectively.

Doctor and patient related reasons
Eighteen respondents referred to factors associated with the interaction between doctor and patient. There was a pervading feeling that patients' cultural backgrounds, beliefs and attitudes, and levels of understanding resulted in certain expectations that sometimes clashed with the requirements of clinical effectiveness. A commonly cited example was patients demanding to be prescribed antibiotics for respiratory tract infections that were likely to be viral. Other examples were requesting investigations when the results were likely to be negative and requesting inappropriate referrals.

Environmental reasons
Factors extraneous to both doctor and patient were mentioned by 19 respondents. The concern most commonly referred to (by 13 respondents) was that of time, and the strength of feeling about this was considerable. Time was seen as hindering effectiveness across all its dimensions"Time influences everything. It influences getting a history correctly, engaging with the patient if you don't know them well, building up some sort of rapport, discussing treatment options, examining them properly." Lack of time was felt by many respondents to result in ineffective practice because it led them to bow to inappropriate patient demands"It may be a Friday afternoon, I want to rush off. I want to prevent this patient calling us back on Saturday afternoon, and I would prescribe antibiotics."

Questioning behaviour
We asked the general practitioners to indicate the sources of information they use when they have unanswered clinical questions about particular patients. All 24 respondents mentioned a practice partner or a hospital doctor, or both. Recourse to literature (books, journals, use of a library) was mentioned by 10 respondents, referral to outpatient clinics by four, the internet by two, and the Medline database by one doctor only.

Changes in clinical practice
We also asked what changes individual respondents had made to their own clinical practice over the past few years. A total of 17 respondents recalled 39 changes, most recalling up to three changes. These ranged from switching to a different drug or using an investigative test for the first time to changing management (such as using a lower treatment threshold). Three main categories of reasons accounted for 25 of the changes, either alone or in combination. Contact with a hospital doctor or observation of hospital practice through seeing patients after their hospital visit was given as the sole reason for six changes, journal articles were cited as the sole reason for five changes, and scientific meetings were given as the reason for four. Four changes were attributed to literature combined with hospital contact, four to scientific meetings and hospital contact and two to literature and scientific meetings. Reference to journal articles was commonly along the lines of, "I remember reading something about it," and did not indicate a literature search or a critical appraisal process. Various reasons were given for the remainder of the changes. Five respondents spoke of a "crystallisation" or an "evolving process" incorporating several sources when elaborating on how the changes had come about.

	Discussion

Top Abstract Introduction Participants and methods Results Discussion References

The findings of our study 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

Limitations of study
The 24 general practitioners who participated in our study formed a small sample that was neither random nor representative and came from only one NHS region. However, given the basis on which they joined the study, it seems reasonable to assume that their interest in clinical effectiveness would, if anything, be greater than that of most general practitioners.

Doctors' concerns
The respondents seemed to be acutely aware of, and sensitive to, patients' expectations and were inclined to judge their practice in terms not only of clinical outcome but also of a patient centred interpretation of quality. Thus, in situations where the requirements of clinical effectiveness openly clash with the preferences or circumstances of individual patients, the latter might take precedence in shaping general practitioners' actions. This concurs with theories on the "holistic" nature of general practice, in which biomedical, personal, and contextual perspectives converge in the decision making process.⁸ The linear decision making suggested by the model of evidence based medicine, informed chiefly by normative standards of clinical effectiveness, sits uneasily within this framework.

Doctors' information seeking
When faced with clinical uncertainty the respondents in this study seemed to make more use of their colleagues or hospital doctors than of scientific literature. This finding is supported by those of Barrie and Ward, who found that "desktop" and human sources were used to answer most of the questions that general practitioners generated during consultations and that literature was little used.¹⁰

Limitations of practising evidence based medicine
There is a growing literature on the shortcomings of the evidence based medicine model in general practice, including the scope and nature of the evidence available and its limited applicability in this aspect of patient care.^12-14 The difficulties in disseminating evidence, identifying the best format for it, and overcoming organisational barriers to implementing it have also been examined.¹⁵ Proponents of evidence based medicine have identified a number of problems and suggested ways of addressing these.⁵