Transcripts for 11 meetings were available for analysis. Two of the groups met six times each, and the third once only—that 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).
Main themes from data
The process of implementing clinical evidence is affected by the personal and professional experiences of the doctor
The relationship that the doctor has with individual patients also affects the process
There is a perceived tension between primary and secondary care: the doctors thought that specialists approach evidence based practice differently
The practitioner's feelings about their relationships with patients and about the evidence have an important role in modifying how clinical evidence is applied
The doctor's choice of words in consultations can sway patients to accept or reject clinical evidence. Doctors realise this and can use it to pre-empt patients' decisions
Implementation comes up against logistical problems, which affect how evidence is applied
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.
Two influences were relevant: the doctors' life experience and experience of hospital medicine as students or juniors doctors. “My grandfather died when he was shocked,” recalled one participant, discussing anticoagulation in atrial fibrillation, “so I reach for a decent dose of warfarin and digoxin no hesitation at all.” Another said: “I actually had two 50 year olds who had strokes from atrial fibrillation because they didn't get warfarin . . . that really hit me.” In another group, one general practitioner said, “ I lost a patient as an SHO, so that puts me off warfarin.”
Accidents, mishaps, or spectacular clinical successes have a direct influence on subsequent practice. Commenting again on anticoagulation in atrial fibrillation, a participant exclaimed, “I'm back on it.” This doctor had previously been uneasy about anticoagulating patients in atrial fibrillation but had recently seen one of his patients who was not given warfarin have a cerebrovascular event. This theme was taken up in another group: “But I suppose if we had a run of people who . . . then had terrible hemiplegias and ended up being a huge workload on the community . . . if we saw the ones the papers were talking about, we would probably be warfarin zealots, wouldn't we.” One doctor summed up this view. thus: “We are influenced at least as much, if not more, by the experiences of individual patients as we are by the evidence.”
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.”
Patients could influence clinical decisions as a result of their own experiences. “Well he's a farmer, so every time he calls the vet he gets antibiotics.” Another patient reportedly said, “My brother died on warfarin, I'm not taking rat poison.” Some doctors found that personal relationships tended to make practising evidence based medicine “harder because you have a close relationship with them.” At other times patients could simply block a doctor's attempts to practise evidence based medicine: “Sod that, says the patient, I'm fine.”
The assumptions doctors made about their patients seemed at times paternalistic. Some were described by their doctor as “ the type who did not want to rock the boat,” others as “depressive cum fatalist.” “Somatisers,” declared one doctor, “eventually get something.” By using these descriptions, the contributors were suggesting that their view of the patient modified how and when they applied the evidence.
One doctor built up the relationship with the patient by initially not following the guidelines and then, in a position of greater trust, was able to implement the guidelines properly. “I have now followed the guidelines of course, but in a sneaky way and it's taken about three months to do it.”
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.”
Specialists were accused of failing to realise just how tricky it was controlling some common diseases. “You get stroppy letters from the clinic saying your patient's blood pressure is still 160, and I go . . . yes, yes, I know. You feel under pressure from the guidelines, but you know it's not from want of trying.” In one group, quite a fundamental difference in approach to clinical practice between primary and secondary care was described. “A few hypertensives, without any symptoms, they're well. They're just running a risk. We give them a drug and a side effect—change the quality of their life,” said one doctor. A female participant in the same group agreed, saying, “Show me one GP who doesn't think like this, show me one cardiologist who does. I mean, this is the problem, isn't it?”
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.”
Another aspect of this theme reflected the doctors' feelings about the consequences of failing to act on clinical evidence. One participant poignantly described how, after the death of a young man who had been inadequately anticoagulated for a venous thrombosis, he felt unease “standing behind his widow in the greengrocer queue.” Another group, taking up this theme, distinguished between probability and certainty, reflecting the tension general practitioners feel about predicting the clinical course in any one person: “You don't know, do you? You just don't know.”
The group discussions also produced data that indicated doctors' familiarity with the evidence and a positive attitude to it. They described its importance to everyday practice: “I think it's always the basis for most of what I do . . . it's fundamentally evidence based but it's tailored completely.” They recognised that evidence based medicine gives new emphasis: “That is the one that I have been hammering, the diabetic blood pressures, to try and get them to 140/80, and I am certainly getting them better than I was but it is hard work.” For some of the general practitioners evidence based medicine was revolutionary: “I think that is the first time I have become aware of one study, or group of studies, that has actually changed my practice within a week.”
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.
The participants realised that this in effect “pre-empted” the decision that they were encouraging patients to take during consultations. Some talked of “selling” a particular view on clinical evidence. This tension between encouraging autonomy and effectively limiting options by the slanted presentation of relevant material was a relatively strong theme: “I make these judgments in theory with the patient but probably on my own.” Another contributor described the problem as, “How much are we obliged to persuade people, or do we let them make up their own minds?”
The choice of words or the use of metaphors like “slanting” or “selling” were mechanisms the doctors used to influence patients to make a decision about their treatment that was consistent with what the doctor had decided was appropriate. Doctors would refer to “rat poison” when describing warfarin if they felt its use would be difficult or inappropriate, or describe pills as “having been shown to keep the heart young” when they wanted a patient to agree to treatment. When a doctor argued that it “depends on how you feed information to people,” other members of the focus groups debated the issue hotly: doctors might influence decisions, they said, but patients can refuse to accept advice too.
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.”
Complications always tended to happen “over the weekend,” and those practitioners who, for example, did not always have nursing staff to help do blood tests seemed to be less enthusiastic about implementing evidence on anticoagulation. When discussing the potential side effects of warfarin, one participant said, “ It's not a minor bleed if your patient is 30 miles from the nearest transfusion service.”
Knowing the patient's personal situation influenced implementation too. Doctors took into account the patient's behaviour, capabilities, or rural location when making decisions. One doctor felt reluctant to anticoagulate one 88 year old woman because “she had an alcohol problem, kept falling. She was forever in casualty being stitched up, bandaged up, whatever.”
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