Introduction

Top Abstract Introduction Participants and methods Results Discussion References

Evidence based medicine is based on universally appealing ethical and clinical ideals in that it promotes the identification of the best methods of health care and helps patients and doctors to make better informed choices.¹ Its framework for searching out and critically appraising evidence helps doctors ask answerable questions to help patients make appropriate decisions.²

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.³ Numerous strategies to improve implementation of such evidence have been tested,⁴ and various impediments have been identified.⁵ General practitioners have been cautious about the evidence based model generally.⁶ In one study that asked general practitioners why they depart from evidence based practice, the commonest reason was reluctance to jeopardise their relationship with the patient.⁷ Apparent hesitation in applying evidence in specific clinical areas such as atrial fibrillation has been attributed to patients' unwillingness to take the drugs.⁸

In a recent questionnaire study of general practitioners' attitudes to evidence based medicine, answers to an open question suggested that there are unique barriers to implementing evidence in general practice within a patient centred context.⁹ This study set out to explore the issues raised by these responses. 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. The hospitals were in the south west of England and covered the area served by a single primary care research network. Each area is geographically separate by about 80 km and tends to develop its own medical community. The groups did not contact each other throughout the study and were not in regular social or professional contact outside the study. By using these separate groups, we aimed to improve the trustworthiness of the data.

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. This style of group work is widely recognised in general practice, and derives from the work of the psychotherapist Michael Balint.¹⁰ The focus groups were not pure Balint groups because they did not include a psychoanalyst. However, a widely used modified form of these original Balint groups has become common in general practice.¹¹ 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. Basic rules of confidentiality are a prerequisite for convening the group, and the participants agree not to discuss material raised in the group outside. The same group of doctors met on several occasions in the hope that, as the group matured, they would feel more comfortable about exploring honest reasons behind their failure to implement evidence.

The groups consisted of six to eight volunteer general practitioners, each led by an experienced group leader. The group leader was given an honorarium to lead and administer the groups and operate the tape recorder. The plan was to have the groups meet about once a month on six occasions, each meeting lasting about two hours. Two of the groups consisted of doctors from different practices and one group comprised doctors from one practice. Participating doctors represented a mix of urban, rural, and semirural practices. There were a total of 19 doctors: 13 men and six women. Their length of time as a principal varied from three to 25 years. Fourteen held the membership examination of the Royal College of General Practitioners, and seven were general practice trainers.

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. Participants were advised to anonymise the patient details and not present any material that could lead to the identification of a particular patient. 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. We explained that the individual doctors would be anonymous. We had no further contact with the groups. We returned copies of the transcripts to the groups, and each member understood that if they were not happy with the content that transcript would not be used.

The meetings were taped, and the tapes delivered to us. The tapes were transcribed, and each researcher separately analysed the transcripts. Each researcher used a grounded theory approach in developing theoretical principles (or at least explanatory principles).¹² This was to ensure that the coding of themes consistently and robustly followed grounded theory rules and that all the emerging themes were directly supported by verbatim data from the meetings. We did not set out with the overarching aim of generating theory from the findings.

We met to compare analysis and identify common themes. To ensure compatibility of analysis, we each analysed three transcripts jointly and the others separately. For the separate analyses, we were given the transcripts recorded out of our own area to minimise the recognition of names, accents, or circumstances that could lead to the identification of patients or participating doctors.

	Results

Top Abstract Introduction Participants and methods Results Discussion References

Transcripts for 11 meetings were available for analysis. Two of the groups met six times each, and the third once onlythat is, 13 meetings. The recordings of two of the groups could not be used because of poor sound quality.

The main clinical areas the general practitioners discussed included hypertension, ischaemic heart disease, and anticoagulation. Other topics developed in the groups discussion included diabetes, chronic obstructive pulmonary disease, menorrhagia, cholesterol, and the use of investigations. Six main themes emerged from the data (box).

Personal and professional experience of practitioner
Our data show that doctors' personal and professional experiences influence how clinical evidence is implemented. 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.

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. "Of course, if they're the sort who always want the specialist, then you follow their [the specialist's] advice." Another explained, " I think you have to judge how people feel about it. I try to get patients to reveal to me where they lie in the game . . . from I want it mate to I don't want to know nothing about it doc . . . I make tremendous judgments."

Perceived tension between primary and secondary care
The general practitioners talked at length about their relationships with secondary care doctors. They felt that specialists 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. "They do seem a slightly different breed," one general practitioner said, referring to cardiologists. A doctor in another group described cardiologists as "being a bit of an evidence based mafia."

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 him [the patient] feel more anxious." Sometimes the knowledge that the evidence existed, waiting to be applied, was seen as a burden in itself: "We get bogged down with perhaps putting the evidence first and consecrating it."

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 contributors framed these themes with phrases such as "It's how you put it over," and "It depends on how you feed information to people." 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.

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."

	Discussion

Top Abstract Introduction Participants and methods Results Discussion References

This study suggests that the general practitioner acts as a conduit in consultations in which clinical evidence is one commodity. For some doctors the evidence had clarified practice, focused clinical effort, and sometimes radically altered practice. But a stronger theme from our data is that doctors are shaping the square peg of the evidence to fit the round hole of the patient's life. The nature of the conduit is determined partly by the doctors' previous experiences and feelings. These feelings can be about the patient, the evidence itself, or where the evidence has come from (the hospital setting). The conduit is also influenced by the doctor-patient relationship. The precise words used by practitioners in their role as conduit can affect how evidence is implemented. In some settings, logistical problems will diminish the effectiveness of the conduit.

Strengths
The strengths of our study derive from the fact that three groups were held separately (enhancing the trustworthiness of identified themes). There was good concordance in the analysis of jointly reviewed transcripts, and validation by respondents did not show serious disagreement with the analysis. One group could not continue in the study, and dropped out. This group consisted of doctors in a single practice; one of the partners was enthusiastic about the project but was unable to sustain the other partners' interest. Because the group consisted of doctors in a single practice, the discussions involved the whole practice allocating time whereas in the other groups, individual general practitioners made their own arrangements to attend.

Implementation of evidence
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 groupsfor example, to discuss implementation generallythe 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.