BMJ  2003;327:E84 (4 October), doi:10.1136/bmjusa.02010004 (published 4 September 2002)

BMJ USA: Letter

RAPID RESPONSES FROM BMJ.COM

Best practice is best in general practice

This article originally appeared in BMJ USA

Editor—I commend Freeman and Sweeney on a fascinating piece of work. Firstly, their modern use of Balint's techniques worked well and has produced some fascinating insights into the use of best practice by GPs. Secondly, it is clear that GPs are tailoring best evidence to the needs and circumstances of individual patients—this is exactly what is intended!

Hoorah for GPs for not being terrorized by the evidence mafia! Hoorah for their sensible, reasoned responses to the emperor's new clothes.

University College, Worcester, UK p.mcdonald{at}worc.ac.uk

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"Old habits"

Editor—"Old habits die hard!"—surely the most obvious explanation for these findings.

Port Adelaide Community Health Service, South Australia 5015, Australia plake{at}health.on.net

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Better communication helps

Editor—One way of rectifying the perceived gap between the "evidence-based mafia" in secondary care and GPs at the coal face is better communication. I find that a quick telephone call can make all the difference when encouraging GPs to institute new drugs or change existing therapy. The opportunity to discuss a patient and his or her particular idiosyncrasies over the phone can be invaluable. We don't communicate by letter alone within the hospital environment, so why do it between primary and secondary care?

Wellington Hospital, New Zealand kgperrin{at}hotmail.com

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Identifying barriers and facilitators

Editor—Freeman and Sweeney describe reasons why GPs do not always apply research evidence to their clinical practice. In 1997 we conducted a similar qualitative study, based on interviews with 44 doctors,¹ in parallel with a quantitative study of the relationship between characteristics of doctors and their prescribing behavior.² Our findings support those of Freeman and Sweeney, in that doctors' attitudes were strongly shaped by personal experience with individual patients, the views of local hospital consultants, and the practical logistics of general practice.

The enthusiasm for guidelines in medicine is based on an assumption that if doctors are told more clearly what to do (based on evidence where possible), they will "improve" their clinical practice. We found that almost all GPs were well aware of the evidence, but did not always implement changes for many reasons, including lack of motivation linked to perceptions of being over-worked, or structural practice issues (such as inadequate computer systems) that made it difficult to make the changes in an efficient way. There was also much ambivalence about the concept of evidence-based medicine, with some viewing human values such as caring for patients and the application of evidence as contradictory. The tension between "giving in" to patient demand and evidence-based practice was a recurrent theme. Some doctors also had quite sophisticated views about the limitations of research findings in relation to individual patients, and were skeptical about the "hidden agendas" of researchers. On a more positive note, we also identified factors that facilitated change, including involvement in teaching or research, a supportive but challenging team environment, and the presence of at least one innovative partner.

In order to change doctors' behavior, we need to develop strategies that recognize and address these barriers and facilitating factors, rather than sending them ever-more guidelines.

Division of Primary Health Care, University of Bristol Cotham House, Cotham Hill Bristol BS6 6JL, UK c.Salisbury{at}bristol.ac.uk

Winchester, Hampshire, SO22 5EF, UK

Edgecumbe Consulting Ltd, Bristol BS8 3ES, UK

Department of Bio-engineering, Bagrit Centre, Imperial College, London SW7 2BX, UK

References

1. Wilkinson EK, Bosanquet A, Salisbury C, et al. Barriers and facilitators to the implementation of evidence-based medicine in general practice: a qualitative study. Eur J Gen Pract 1999;5:66-70
2. Salisbury C, Bosanquet N, Wilkinson EK, et al. The implementation of evidence-based medicine in general practice prescribing. Br J Gen Pract 1998;48:1849-1851 [ISI][Medline]

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