Background

Evidence-based medicine (EBM) has emerged as an influential model for the teaching and practice of clinical medicine. Although the concept has been successfully disseminated in the health care field, there have been numerous criticisms advanced. Arguments have been put forth that EBM represents reductionism by its narrow definition of evidence; ignores the legitimacy of clinical judgement, experience, and the time constraints of non-academic practice; fails to include and respond to patient values; fosters an inappropriate reliance on epidemiology and statistical methodology, particularly a dogmatic adherence to the RCT; lacks empirical justification; and is poorly specified for some aspects of clinical medicine such as primary care [1–7].

The legitimacy of these criticisms has been hotly debated [8, 9]. Partly in response to the critics and the admitted shortcomings of the original formulation of EBM, there has been a transformation within EBM itself as exemplified by the proposed distinction between evidence-based practitioners and evidence users [10] and the newly-articulated framework highlighting the interaction among clinical expertise, patient preferences and values, research evidence, and clinical state and circumstances [11]. These significant modifications to the original model indicate that EBM is an evolving methodology currently in transition. Polemics aside, however, there is little empirical evidence of how evidence-based practice is actually perceived by physicians in relation to clinical expertise and patient preferences. Such empirical investigation is essential to harmonising the stated goals of EBM with the realities and expectations of clinicians and patients. Thus, the objective of this study was to investigate physician attitudes to and experience of the practice of EBM in primary care, specifically with respect to the influence of patient preferences and the role of intuition in clinical decision-making.

Methods

Participants and setting

This paper reports on the qualitative component of a larger multi-methods project based in the Primary Care Research Unit at Sunnybrook & Women's College Health Sciences Centre in Toronto, Canada. The study, which was approved by the Research Ethics Board of the host institution, was carried out between July and November of 2002. Previous to this, we had conducted a national survey of Canadian family physicians on the practice of EBM in primary care; as part of the mail-out package, all survey recipients (target sample = 1134) were additionally invited to participate in a follow-up qualitative study. A total of 64 survey respondents indicated a willingness to be interviewed by signing and returning a reply post-card. The demographic characteristics (age, gender, practice setting) of this sub-set of 64 willing physicians mirrored quite closely those of the overall target sample of 1134. We purposively sampled from this list to reflect diversity with respect to age, sex, practice setting (urban/rural), and geographic location in Canada (east/west). We contacted a total of 23 physicians to invite their participation in the study; 15 agreed to be interviewed, five did not respond to our invitation, and three were unable to participate owing to time constraints.

Our final sample comprised eight female physicians (53%) and seven males (47%). The age distribution of participants was as follows: 27% (n = 4) were 25–39 years of age; 47% (n = 7) were aged 40–54 years; and 27% (n = 4) were 55+ years of age. The mean number of years in clinical practice was 16.3 years; the mode was also 16 years. Two-thirds (n = 10; 67%) of participants reported practicing in urbanized regions, while the remaining one-third (n = 5; 33%) practiced in rural areas. The majority (n = 10; 67%) were part of a group practice; three (20%) were in solo practice; and two (13%) practiced exclusively in locums. Most participants (n = 10; 67%) reported having internet access in their office/clinic and most (n = 12; 80%) also reported some degree of involvement in education (teaching of medical students, supervision of residents, etc.). A detailed demographic profile of the 15 individual participants is presented in Table 1.

Table 1 Demographic profile of participants
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Data collection and analysis

We employed a grounded theory approach, which is particularly well-suited to exploratory studies of this nature [12]. Two of the authors (CST and GCD) shared the task of conducting the interviews based on a random assignment of participant to interviewer. We utilized a semi-structured interview schedule that was developed with input from researchers and academic clinicians and then pilot-tested on three primary care physicians at the host institution. All interviews were conducted by telephone and were audio-taped with the participants' consent; the interviews typically lasted between 30 and 40 minutes. Data collection continued until there was agreement among all three authors that saturation had been reached.

Each interview was transcribed verbatim, following which the accuracy of the transcription was verified by the interviewing author (to allow for clarification of any inaudible passages). The first two authors independently read and coded each successive transcript as it became available and organized the data into broad theoretical categories. In order to test for credibility, emerging themes from the early interviews were explored in subsequent interviews, consistent with the 'constant comparative method' [13].

At the completion of data collection, the first two authors (CST and GCD) each prepared a list of main themes and representative quotations for purposes of comparison. Instances of disagreement were resolved through a process of discussion and negotiation that included the third member of the research team (REGU). Throughout the analysis process, we maintained a conscious search for contradictory cases. Our analysis of the data yielded six major substantive themes which are presented below.

Results

Benefits and barriers

The vast majority of respondents welcomed the promotion of EBM in family practice; however, participants also enumerated a significant list of barriers and limitations pertaining to implementation (Table 2). Among the many perceived benefits of EBM were improved standards of care, enhanced doctor-patient communication, superior formatting of information, and decreased complacency regarding practice patterns. At the same time, there was a widely-shared belief, even among some of those who most welcomed the introduction of EBM, that the initiative did not reflect a genuine paradigm shift in the practice of clinical medicine, but rather reflected a "rebranding" of sorts. Several physicians explained how they utilise research evidence to provide patients with treatment options; others reported using the evidence to justify their clinical decisions.

Table 2 Quotations: Benefits and barriers
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The most commonly mentioned barrier to the practice of EBM was insufficient time owing to an extremely heavy workload. Limited resources and a lack of local specialists were also common concerns, particularly among rural physicians. The majority of respondents pointed to the problem of generalizability as an important limitation of EBM as it is currently structured. Finally, there were a number of barriers pertaining to issues of access. A small minority reported having no or limited access to the Internet at their office; those with easy access complained that it is often difficult to find information and that, once found, it is typically not in user-friendly formats.

Constraints on practice

Despite generally positive views, EBM is perceived by some as a devaluation of the 'art of medicine' or a threat to their clinical autonomy, or both (Table 3). Participants expressed concern that EBM is leading to less flexibility and less room for creative problem-solving in family practice. Evidence-based guidelines were described as a constraining force on family physicians; one physician expressed her fear of forced adherence to guidelines and another believes that her competency is doubted when she deviates from the evidence. On the other hand, when prompted, a small number of respondents indicated that they do not share these views or experiences.

Table 3 Quotations: Constraints on practice
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Trust and credibility

There was a tremendous level of concern on the part of respondents with respect to issues of credibility, bias, and the trustworthiness of evidence (Table 4). This anxiety was most readily apparent in physicians' expressions of unease and apprehension regarding the role of the pharmaceutical industry in the funding and conduct of clinical research. Many interviewees specifically decried the growing influence of pharmaceutical manufacturers on decisions about the type of trials that get funded and the sort of findings that get published; indeed, the consensus was that there is an overwhelming need for more independent research to reduce industry bias.

Table 4 Quotations: Trust and credibility
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Conflicts and decision-making

All participants reported the experience of conflicts in their efforts to practice EBM (Table 5). After having considered the available research evidence, it is not uncommon for physicians to act contrary to evidence, most typically because they deemed the results to be inapplicable to the present clinical context. Also, it would appear that patients' preferences are often at odds with the evidence and that in these cases physicians are inclined to act in accordance with the wishes of patients. A third type of conflict arises when there is no clear consensus within the literature – either there is directly conflicting evidence or a consensus is only beginning to emerge. In such cases, the majority of respondents rely on past practice to inform their decision-making.

Table 5 Quotations: Conflicts and decision-making
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Patient factors

Patient preferences, values, and expectations appear to exert a tremendous influence on the clinical decision-making of these family physicians (Table 6). Many participants noted that patient preferences can and often do determine the direction of the treatment plan. Indeed, most of the physicians in our sample reported that when patient preferences directly collide with other factors – whether it be evidence from published studies, local practice patterns, etc. – the tendency is to do what the patient wants. On the other hand, a small number of participants expressed a reluctance "to give in to the patient." Managing patient preferences/expectations is seen as one aspect of the 'art of medicine' that many participants referred to as a casualty of the increasing reliance on EBM.

Table 6 Quotations: Patient factors
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The role of intuition

There was overwhelming agreement that intuition plays a vital role in the practice of family medicine (Table 7). While the definitions varied from one physician to the next, a recurring element was that intuition has its origins in personal clinical experience. Even those participants who argued in favour of the promotion of EBM and described themselves as evidence-based practitioners included intuition among the necessary tools for strong clinical decision-making. Indeed, EBM and intuition were perceived as complementary rather than opposing one another. Many respondents referred to research evidence as a 'starting point' – it was not thought of as 'a bible.'

Table 7 Quotations: Role of intuition
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Discussion

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, 18].

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 [19–21]. 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.