We believe that our findings are relevant to both producers of evidence and practising clinicians. In addition to studies demonstrating that particular evidence is incorporated into practice,20
our study offers a macro-level perspective on the place of evidence-based medicine in family practice. To our knowledge, these are the first research data to indicate that Canadian primary care physicians are incorporating evidence-based medicine into their daily encounters with patients, even if they are not fully embracing it. Examining both the obstacles and the opportunities for the application of evidence provides important clues to providers of evidence-based information of interest to primary care.
Greater involvement of family physicians in guideline development would help to ensure that sufficient details are provided to make the guidelines of optimal value to family practice. Our participants expressed concern about differences between their patients and trial populations. Therefore, authors of guidelines or consensus statements need to give clinicians enough detail to permit the interpretation and application of trial evidence to the individual patient. Even secondary journals, which screen the primary literature and provide summaries of important articles, “often” omit important information about study design, methods and results.21
These family physicians identified a range of opportunities for using evidence in patient encounters, including cardiac events, such as myocardial infarction, or changes in medications. Particular tools, such as cardiovascular risk tables or evidence-based decision aids, may be effective for demonstrating the applicability of research findings to individual patients. Also, patients have unprecedented access to health information (e.g., through the Internet). Although their use of such resources may be burdensome or even threatening to family physicians, it offers a unique opportunity for discussions of evidence and its reliability. Bookmarking sites that have been reviewed and deemed credible, to serve as “quick-response” sources, is one helpful strategy.22
These family physicians recognized that specialists promulgate and interpret evidence, and are particularly attentive to whether evidence is relevant to their practice population. At the same time, evidence-based medicine might empower family physicians to make alternative choices for their own patients by giving them the skills to discuss or challenge specialists' decisions. A spectrum exists among family physicians, ranging from uncritical reliance on specialists' advice to rejection of that advice on the basis of their own interpretation of the evidence. Individual physicians may also take different approaches in different situations.
Our findings raise several questions. Do all clinicians require critical appraisal skills or is a system for peer appraisal at both the national and local levels a more promising model for fostering the application of evidence? What is the most effective way to convey difficult risk–benefit statistics to patients so that they can make well-informed decisions about their own treatment? Finally, do patients find the discussion of evidence helpful, meaningful and empowering, or do they find such discussions esoteric and obfuscating?
This inquiry was limited to evidence pertaining to cardiovascular disease, which is both plentiful and strong, and hence our findings may not be applicable to other clinical problems. Another limitation is that our study focused on clinical encounters with patients; we did not fully pursue whether family physicians considered the role of evidence in framing consultants' decisions and advice. Further inquiry is needed in different contexts and for different clinical conditions to develop the ideas generated by this study.
Decisions about the application of evidence in primary care settings are highly complex, shaped by such diverse factors as patients' understanding of and interest in their own health, comorbities, individual physicians' use and understanding of current evidence, and the changing nature of evidence itself. This conclusion supports the balance emphasized by the Evidence-Based Medicine Working Group itself.23
A key point is that not only is the evidence that might be used in the family practice setting complex, but it may be contested by patients who have different goals or who wish to pursue different paths in their health care. Our findings suggest that any debate about the completion of the paradigm shift toward reliance on evidence needs to account for the realities of primary care and for particular clinical content.