Bandolier 55 pointed to work examining how evidence-based medicine was regarded and
used in Wessex in 1996. We now have an update from Sydney in 1999 [1]. Different
continent, similar results, and some important messages.
Evidence based practice is usually put into the context of
- framing a question,
- locating evidence,
- appraising the evidence,
- applying the evidence and then
- evaluating performance.
Fine ideals, but a tad difficult on a wet Tuesday in Grimsby in the middle of a 'flu
epidemic. General practitioners might be forgiven for a healthy degree of scepticism:
the magic is that so many of them enthuse about the use of evidence despite the
numerous obstacles they face.
Study
The new study was conducted among 60 GPs in Sydney in mid-1999. It used generally
similar methods and questions as the previous Wessex survey [2], but with additional
questions. Sixty GPs participated, and all returned their questionnaires.
Results
Access and understanding
Two-thirds of GPs had access to the Internet at home or work, but only 8% had access
to the Cochrane Library. Australian GPs were generally favourably inclined towards
evidence-based medicine, but knowledge of technical terms to the level of being able
to explain them to others was low. Only one in five had the confidence to do this for
systematic review and one in ten for confidence interval. By contrast for most
technical terms between a third and a half of GPs admitted to not understanding them,
but wanting to.
Barriers to EBM
Important barriers to the use of evidence-based medicine were four: unrealistic
patient expectations, time, skills and money.
The largest single barrier, noted by almost half these Australian GPs, was that
patients demand treatment despite a lack of evidence of effectiveness, and one GP in
five was concerned about unrealistic patient expectations driving treatment choice,
rather than the evidence.
Time was a huge problem, whether for locating, reading and appraising evidence, or
for discussing the evidence with patients. One in four GPs was worried about the cost
of purchasing resources for evidence-based practice, and lack of skills was important
to a minority of GPs.
Useful resources
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Clearly top were evidence-based clinical practice guidelines, and journals
summarising important research evidence, like Evidence-based Medicine and
Bandolier
. Systematic reviews, or original articles, including the Cochrane Library, were
bottom of the list.
Comment
This paper carries some critical messages. The first is that any organisation
wanting to support GPs has to "Get Real!" These are busy, overworked people. The
will is there to use evidence-based medicine, but not the time. They need skills
teaching and easily assimilated digests of evidence, preferably with quick
Internet access so they can get it within three clicks when they need it.
Organisations trying to force all the responsibility downwards need to know that
it just won't work.
Look at it in a positive way. Organisations need to help GPs with education on
evidence-based medicine skills and understanding, so they can have confidence in
advice given them, from whatever source (health service, pharmaceutical company,
expert opinion). Then provide them with digests - simple to read with a clinical
bottom line at the top. Then put it on an Internet or intranet. We call it the
Internet version of
Bandolier
, so it can be done.
There's another lesson about barriers. It's one thing to help and educate GPs,
but we now have vociferous patients demanding their "rights". That might include
some completely useless treatment, like homeopathy, that we know doesn't work.
GPs in particular need to be protected from decisions like this (after all, which
of us questions our anaesthetist?). Patients themselves must become targets for
education about evidence. They will have to acknowledge the balance between a
right of access to a treatment known to work, and responsibility to purchase for
themselves treatments known not to work.
References:
- JM Young & JE Ward. Evidence-based medicine in general practice:
beliefs and barriers among Australian GPs. Journal of Evaluation in Clinical
Practice 2001 7: 201-210.
- A McColl et al. General practitioner's perceptions of the route to
evidence-based medicine: a questionnaire survey. BMJ 1998 316: 361-365.
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