Primary care physicians appear to value the principle of clinical decision-making informed by research evidence, but there exist many significant concerns pertaining to conflicts, implementation barriers, bias, clinical autonomy, and scientific reductionism. The overall sentiment toward EBM in this sample of family doctors might best be characterized as 'guarded optimism.' We also discovered that primary care physicians place great value in the role of intuition in clinical decision-making.
The strength of our study derives from the sample, which was comprised of male and female family physicians of all age groups from across Canada in both urban and rural settings, solo and group practices, and with a wide range in years of clinical experience. Our study is limited because the interviewees were initially self-selected from among approximately 1150 physicians invited to participate in a national postal survey. We cannot, therefore, be certain that our sample is representative of the population of Canadian family physicians (despite a concerted effort to maximise representativeness by seeking participants of various age groups, practice settings, geographic locations, etc.). It does appear that the percentage of physicians in our sample who are involved in teaching activities (80%) is out of proportion to that of the wider Canadian physician population (25%) [14
]. At the same time, while an academically-inclined sample is likely to be better informed about EBM, it not necessarily more receptive or more opposed; that is to say, the bias is likely non-directional.
Our data is consistent with previously published studies indicating that physicians hold mixed views toward the promotion of EBM in primary care. For instance, a postal survey of British general practitioners revealed that while the majority are welcoming of EBM, only a very small proportion (5%) believe that the most appropriate method of moving towards EBM is for primary care physicians to learn the necessary skills (i.e., identifying and appraising the scientific literature) [15
]. Likewise, the findings of a qualitative study of general practitioners in three Australian cities suggested that the majority are simply not interested in learning the fundamental skills of critical appraisal [16
]. It is not surprising then that the EBM skills of primary care physicians tend not to be particularly well developed [17
Our study also reinforces that there are a number of structural barriers to the implementation of EBM – many of which are unique to the primary care setting [19
]. A recent Canadian study of the role of evidence in primary care found that while family physicians are increasingly making use of clinical research findings in the course of daily practice, such evidence is not viewed as absolute but rather is considered in conjunction with a diversity of other factors [22
Clinical decision-making is indeed a complex, multi-factorial process. Despite this, the architects of the original EBM paradigm explicitly downplayed several significant components of the decision-making process: "Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale ... and stresses the examination of evidence from clinical research" [23
]. The findings of this study indicate that primary care physicians see no opposition between research evidence and clinical intuition, nor do they believe that evidence always trumps experience, particularly in cases where the evidence is contradictory or patients are expressing strong preferences. Greenhalgh has called for the integration of the 'science' of EBM with the intuitive 'art' of clinical judgement: "It is now time to raise the status of intuition as a component of expert decision-making" [24
]. These results provide the first indication that clinical intuition is valued by clinicians on par with research evidence.
The present results also indicate a deep-seated sense of unease with the credibility of research evidence provided or sponsored by pharmaceutical companies. Concerns pertaining to the credibility and trustworthiness of available evidence are highly troublesome for primary care physicians attempting to make evidence-based decisions. Clearly, more must be done to secure credibility of research evidence. Additionally, patient preferences and expectations appear to exert an important influence on clinical decision-making. Further exploration of the interactions among patient preferences, clinical intuition, and the credibility of research evidence is required.
We conclude that the findings of this study provide empirical support to recent revisions to the EBM model of clinical decision-making that places increased emphasis on the clinical context and patient preferences and actions [11
]. Patient preferences clearly play a role in the shaping of clinical decisions – indeed, we have shown that patient factors can serve as trumps to research evidence – and are therefore fundamental to any model of clinical decision-making. Perhaps most notable, however, is that where once the value of intuition and clinical experience was explicitly de-emphasized by the proponents of EBM [23
], the role of individual clinical expertise now figures most prominently in their revised model [11
]. To be sure, the evidence is mounting that intuition is an indispensable element of clinical decision-making in primary care.