Intended for healthcare professionals

Primary Care

Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care

BMJ 2004; 329 doi: (Published 28 October 2004) Cite this as: BMJ 2004;329:1013
  1. John Gabbay (j.gabbay{at}, professor of public health1,
  2. Andrée le May, reader in nursing2
  1. 1 Wessex Institute for Health Research and Development, Community Clinical Sciences, University of Southampton, Southampton SO16 7PX
  2. 2 School of Nursing and Midwifery, University of Southampton
  1. Correspondence to: J Gabbay
  • Accepted 7 September 2004


Objective To explore in depth how primary care clinicians (general practitioners and practice nurses) derive their individual and collective healthcare decisions.

Design Ethnographic study using standard methods (non-participant observation, semistructured interviews, and documentary review) over two years to collect data, which were analysed thematically.

Setting Two general practices, one in the south of England and the other in the north of England.

Participants Nine doctors, three nurses, one phlebotomist, and associated medical staff in one practice provided the initial data; the emerging model was checked for transferability with general practitioners in the second practice.

Results Clinicians rarely accessed and used explicit evidence from research or other sources directly, but relied on “mindlines”—collectively reinforced, internalised, tacit guidelines. These were informed by brief reading but mainly by their own and their colleagues' experience, their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives, and other sources of largely tacit knowledge. Mediated by organisational demands and constraints, mindlines were iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid “communities of practice,” resulting in socially constructed “knowledge in practice.”

Conclusions These findings highlight the potential advantage of exploiting existing formal and informal networking as a key to conveying evidence to clinicians.


  • We thank Dale Webb, who carried out some of the formal interviews. Above all we thank the staff of “Lawndale” for their forbearance in allowing us to “hang around” over all this time and learn so much from them about the day to day practice of primary care. Thanks also to the “Urbchester” GPs for the very fruitful time spent there.

  • Contributors Both authors jointly conceived and designed the study, did the fieldwork, and wrote the paper. They are joint guarantors.

  • Funding Grant from former Department of Health South East Regional Office R&D Directorate.

  • Competing interests None declared.

  • Accepted 7 September 2004
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