Evidence-based medicine (EBM) is the translation of both the latest best research evidence and clinical experience into individualized patient care.1,2 EBM aims to assist doctors in making evidence-informed decisions and therefore is assumed to reduce unwarranted variations in medical decisions.
Currently, doctors’ use of research evidence in medical decision making clearly varies. Some characteristics of doctors and practice settings may create specific barriers and facilitators for EBM. Awareness of such characteristics can provide insight into how to best target the barriers and facilitators for EBM.
An increasing number of qualitative studies have reported on barriers and facilitators for EBM as perceived by doctors. To date, the available reviews that include these qualitative studies generally focus on barriers to using clinical practice guidelines (CPGs),3–5 or on residents’ barriers to practicing EBM.6 We provide a comprehensive overview of qualitative studies on doctors’ perceptions of both barriers and facilitators for EBM, including, but not limited to, the use of CPGs. We also take into account variability across medical disciplines, career stages, practice settings, and time of study. For this purpose we integrate the findings of primary qualitative studies by a thematic synthesis.7
The method of thematic synthesis was developed out of a need to conduct systematic reviews of qualitative studies, without compromising on key principles in systematic reviews of quantitative studies.7 We adhered to the ENTREQ statement, which provides an explicit and transparent approach for the reporting of thematic synthesis in the context of systematic review studies of published original qualitative studies.8
Data sources and searches
We searched PubMed up to April 26, 2012, combining synonyms for “qualitative studies,” “evidence-based medicine,” and “doctors.” We used a filter for English language. For the complete search syntax, see Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A143.
We only included primary qualitative studies on doctors’ perceptions or use of EBM. To be included in our analyses, at least one-third of a study’s participants had to be doctors, including all medical career stages. Studies had to report practice setting characteristics and allow extraction of data on doctors when other professions were included. Because our focus was on doctors, we did not use any of the data reported in the included studies on health care professions other than doctors. If a study used mixed methods, it had to allow extraction of qualitative data to be included. As we focused on qualitative data, we did not use any of the reported quantitative data reported in the included mixed-methods studies. We excluded non-English articles. After screening titles and abstracts (by M.S. and N.R. or D.I.), we retrieved full-text articles to screen their relevance (by M.S. and N.R., D.I., D.W., or F.V.). We resolved discrepancies by consensus.
Data extraction and quality assessment
To assess the quality of the relevant studies, we extracted data on participants, design, analysis, and results. We only included studies that met all of the following three methodological criteria:
- Using purposive or theoretical sampling. These approaches aim to include the full range of possible cases or settings, so that conceptual rather than statistical generalizations can be made. Purposive sampling ensures that the initial sample includes as many as possible of the factors that might affect variability of perceptions or behavior. In theoretical sampling the initial sample is extended in light of early findings and emergent theory in an attempt to further improve on the range of factors included in the sample.9
- Describing the approach to deriving themes from the data, that is, inductively (obtained gradually from the data) or deductively (more informed and structured by a priori reasoning).10
- Using methodological triangulation, that is, comparing two or more different methods of data collection (such as interviews, observations, and surveys) to look for corroborating patterns of convergent information, which may help in the synthesis and interpretation of data. This approach ensures comprehensiveness and encourages a more reflexive analysis of the data.9
We (M.S. and N.R., D.W., F.V.) independently screened for quality by assessing whether each criterion was satisfied (yes or no) and reached consensus on any discrepancies.
We evaluated the completeness and transparency of reporting in included studies for five domains: research team, study design, data collection, data analysis, and reporting of findings.7 We derived these reporting criteria from the literature.11–17 Supplemental Digital Table 1, http://links.lww.com/ACADMED/A143, defines the reporting criteria for each domain. Results for reporting criteria were not used in selection of studies. We (M.S. and N.R., D.W., or F.V.) independently judged whether each criterion was satisfied (yes or no). Again, we resolved any discrepancies by consensus.
Data analysis and synthesis
Descriptive data coding.
We entered each included study into NVivo8 (QSR International, Melbourne, Australia). M.S. and F.V. independently read all text of results paragraphs, line by line, and interpreted the content of each text fragment (i.e., the subject of EBM being addressed). We coded each text fragment according to the labels of a codebook. For this, we followed an inductive (exploratory) approach, using a fixed classification system for coding. The codebook initially included the headings of a conceptual framework on EBM developed in a previous study.18 For each new aspect of EBM we defined a new descriptive label for the codebook. For each text fragment we also coded the outcome, that is, the “barrier”‘ or “facilitator” for EBM, or “undecided” when the text was ambiguous. For each study we coded the context (i.e., medical disciplines, career stages, practice settings, and publication date). We resolved initial disagreement on wording of descriptive labels and data coding. Our inductive coding of results paragraphs brought about 189 codebook labels on EBM. M.S. and F.V. grouped these labels into “different aspects of EBM” under eight descriptive themes. These descriptive themes summarized the primary studies, closely reflecting their results and conclusions.7
The results of this thematic synthesis depended on the robustness of the available data within each descriptive theme with regard to content, outcome, and context. M.S. and G.H. evaluated the content of each descriptive theme on its conceptual saturation,8 that is, whether we reached the point where no new aspects of EBM were identified and thus no new codebook labels were defined. In addition, we used quantitative NVivo8 matrix tables to evaluate the amount and distribution of the data within each descriptive theme. Regarding the amount of data per descriptive theme, we assessed the number of coded text fragments and the number of studies. Concerning the distribution of data within each descriptive theme, we looked at the distribution frequencies of the studies across the range of outcomes and the contexts. Both the evaluation of conceptual saturation and the amount and distribution of the data showed that the available data within each descriptive theme were sufficient to allow further analysis. Supplemental Digital Table 2, http://links.lww.com/ACADMED/A143, quantitatively demonstrates the amount and distribution of data.
Interpretative data synthesis.
M.S. and G.H. looked for similarities and differences of content, outcomes, and context within and between the descriptive themes. In their search for new interpretative explanations on doctors’ barriers and facilitators for EBM, they sorted and rearranged the descriptive themes into analytical themes. Supplemental Digital Table 2, http://links.lww.com/ACADMED/A143, demonstrates the relationship of descriptive themes to analytical themes. These analytical themes go beyond the results and conclusions of the primary studies.7
The descriptive and analytical themes were reviewed by and discussed with a senior researcher and medical specialist in anesthesiology (C.K.), an expert in qualitative and mixed research methods (H.B.), and a senior clinical epidemiologist (Y.G.).
Figure 1 provides details on study selection (see also Supplemental Digital Table 3 http://links.lww.com/ACADMED/A143, which focuses on selection according to methodological quality). Our search yielded 1,211 publications, of which we included 30 studies19–48 covering experiences of over 1,423 doctors (see Table 1 and Appendix 1).
Studies varied on the five reporting domains, with a mean of 54% of applicable criteria reported per study (range: 39%–86%). Supplemental Digital Tables 1 and 4, http://links.lww.com/ACADMED/A143, define each criterion and show the completeness of reporting for each criterion, respectively.
Five analytical themes emerged: individual mind-set, professional group norms, EBM competencies, balance between confidence and critical reflection, and managerial collaboration. Appendix 2 provides quotes to illustrate these analytical themes.
Familiarity with EBM.
Unfamiliarity with the conventional definition of EBM as “the translation of best evidence and clinical expertise into individualized patient care” was generally viewed as a barrier to EBM. Doctors who viewed EBM as “evidence dominating medical decisions” believed EBM neglected their clinical expertise, and contrasted EBM against the benefits of their clinical expertise in helping individual patients. Moreover, when doctors felt restricted by EBM or were suspicious of potential abuse of EBM by others (e.g., patients, lawyers, or managers), this strongly reduced their sense of ownership and increased their fear of losing professional autonomy or personal reputation.
Attitude towards EBM.
A positive attitude of doctors towards EBM facilitated EBM. When a positive attitude did not result in EBM behavior, doctors were suspected to have provided socially desirable responses about their attitudes.
Attitude towards change.
The ability to change routines is a requirement for EBM, in that doctors need to be willing to incorporate best evidence into their clinical practice. Several barriers to change were reported. Doctors generally felt uncomfortable to go beyond their trusted clinical routines. Those satisfied with their current routines showed reduced need for change. A lower change potential was considered related, on the one hand, to older age, and, on the other hand, to a very strong, inflexible, or insecure personality.
Professional group norms
Culture towards EBM.
Respectful and reciprocal communication among doctors was reported to be a strong facilitator of EBM. In a culture that encouraged EBM, doctors felt safe and supported to share, discuss, and integrate best research evidence in their patient care. Such a culture helped doctors to discuss and challenge medical decisions across career stages, medical disciplines, and settings. Being supported by strong evidence boosted self-confidence of residents and of doctors in subordinate medical disciplines (i.e., medical disciplines that are on the lower rungs of the ladder in the medical prestige hierarchy), and facilitated their communication and collaboration with staff. In contrast, a negative attitude of staff towards EBM, an “expert-based” pecking order, and nonreciprocal communication hampered both the exchange of information and discussion about medical decisions. This intensified feelings of hopelessness and helplessness among residents and subordinate medical disciplines, who thought that authoritarian staff must feel uncomfortable too, as this negative attitude prevented staff from admitting that they also are fallible.
Culture towards change.
Supervisors were a very important point of reference for residents, and experiences with supervisors had long-lasting career impact. Ideas and practice of respected colleagues as well as current and past supervisors strongly influenced doctors’ sense of urgency for identification and uptake of the latest best research evidence. Residents and doctors from subordinate medical disciplines commented that a strong hierarchical order may create a barrier to going beyond staff’s clinical routines.
Knowledge and skills.
Proficiency in applying EBM empowered doctors, especially residents who were aware of their limited clinical experience. A lack of knowledge and skills, however, strongly hindered EBM. Barriers to EBM were reported in all four competencies2 below:
- Asking answerable questions was hampered, particularly in early career stages, by doubts about which relevant clinical information to consider (e.g., patient and disease characteristics) and which terms or synonyms to use (e.g., “sciatica” or “low back pain”).
- Searching best evidence was perceived as too time consuming and unproductive due to the information overload by the large volume of medical research literature and massive CPGs.
- Critical evidence appraisal was commonly reported as very difficult to master. Barriers concerned difficulties in identifying risk of bias and uncertainty about implications of reported intermediate or surrogate end points; incomplete, indirect, or conflicting evidence; and the consequences of negative findings. The rapid growth and replacement of evidence was perceived as a barrier to drawing firm conclusions.
- In translating evidence from the research population to individual patients, limited clinical experience was viewed as a barrier, in particular by doctors in the early career stages. In addition, absence of clear clinical recommendations alongside synthesized evidence (as in CPGs) was considered an important barrier to EBM.
Teaching settings offered more opportunities for shared learning and critical reflection for residents and staff. Integrated EBM education with shared learning “at the bedside” facilitated mastery of EBM competencies for busy doctors in routine clinical practice. In contrast, conventional “standalone” EBM courses had a modest impact on EBM competencies only for doctors with some prior EBM knowledge and skills.
Clinical role models were highly respected for their personal and collegial advice—for example, through informal consultations and academic detailing. Positive EBM role models were in particular considered strong facilitators for integration of EBM in clinical practice.
Balance between confidence and critical reflection
Identification of information needs.
Information needs were expressed most often for areas with rapidly evolving evidence and in urgent and challenging situations. But doctors reported large variations in the extent to which they were aware of and reflected on their knowledge gaps. On the one hand, lack of clinical experience of residents was viewed as a barrier to clear definition of their many information needs. On the other hand, the comfort of clinical experience put doctors at risk of becoming too confident in their own clinical competencies, resulting in poor critical reflection and thereby a lack of awareness of knowledge gaps and ignoring information needs.
Information seeking behavior.
The extent to which doctors searched for information to fulfill their information needs was rather limited. Readily accessible, summarized, clinically oriented, and user-friendly information was in general viewed as a facilitator for EBM. Nevertheless, doctors took little notice of best-evidence summaries, regardless of their ease of access. They preferred information from intercollegial consultations over written sources because they could blend the opinions of respected colleagues and current or past supervisors more easily with their own clinical experience.
Information assessment behavior.
Doctors based their assessment of the relevance and validity of retrieved information primarily on the trustworthiness of the information source. Once they considered the source (e.g., a colleague) to be trustworthy, they assumed that the information itself was relevant and valid. Despite doctors’ expressed skepticism about their trustworthiness, pharmaceutical representatives influenced doctors’ prescriptions of new drugs, especially in general practice.
Translating information to individual patients.
Doctors reported drawing on their clinical expertise when using research evidence in their medical decision making. They used tacit knowledge and implicit benchmarks to make inferences about their average patient. Clinical experience, in particular familiarity with disease patterns, facilitated doctors’ ability to predict the course and outcome of a disease and to identify potential individual problems, such as altered risk status relating to comorbidity. Still, for identical hypothetical patients, doctors had rather limited agreement on predicting the course and outcome of a disease, and on the initiation and continuation of treatment. Variation between doctors depended on what they had learned during medical training, their confidence in current management of patients’ conditions, their prior experience of “trialing” in a few patients, their knowledge of profiles of side effects of treatment, and their perceived fit of the evidence with local facilities.
Adequate communication between doctors and patients facilitated the engagement of patients in the medical decision-making process by including their preferences and managing their expectations. Being supported by strong evidence boosted the confidence of doctors, especially residents, and facilitated their communication with patients. Still, doctors evaluating communication or behavior of identical hypothetical patients demonstrated different interpretations of social cues (e.g., anticipated patient compliance), regardless of the level of clinical experience. Also, some doctors felt that patients were unable to understand research evidence or to tolerate its inherent uncertainty.
Feeling inexpert or insecure and facing time restrictions were viewed as barriers to doctors communicating with patients and to incorporating patients’ preferences in their decision making. As a result, doctors often shifted from shared decision making to a paternalistic approach. General practitioners in particular were keen on building and preserving good patient–doctor communication and long-term relationships. However, avoidance of conflicts in the doctor–patient relationship—for example, by giving in to unwarranted requests (e.g., a demand for redundant treatment) or by avoiding discussion of upsetting topics (e.g., advice to stop smoking)—hindered doctors’ ability to make evidence-informed medical decisions.
Doctors’ use of EBM was deterred by many organizational barriers, such as an inadequate infrastructure for information retrieval (e.g., limited access to preappraised and full-text evidence resources and decision support facilities). Other organizational barriers included high patient and office workload, workforce shortages, lack of mentors, lack of financial incentives, inadequate funding for particular patient groups or expensive treatments, inefficient logistics, lengthy referral time to other disciplines, and insufficient access to diagnostic services.
Doctors viewed adequate communication with management as a facilitator of collaboration for overcoming such organizational barriers to EBM. However, doctors reported waiting for their management to take the first step. Doctors reported intentions or efforts to improve collaboration, including instituting and promoting EBM training and shared learning, monitoring the quality of care and patient outcomes, and building collaborative structures within and across clinical disciplines for these actions.
Discussion and Conclusions
The five major themes that emerged from this synthesis of primary qualitative studies addressed doctors’ barriers and facilitators to using EBM in medical decisions: the individual mind-set, professional group norms, EBM competencies, the balance between confidence and critical reflection, and managerial collaboration. These five themes were relevant to medical decision making across career stages, medical disciplines, and practice settings. We found that encouragement of collaboration by means of safe communication and shared learning across career stages will facilitate the uptake of EBM and reduce cognitive and affective biases in medical decision making.
Our findings show that doctors typically learn in social contexts by doing and by interacting with peers. The impact of context was particularly expressed in specific barriers and facilitators for EBM across career stages. Although staff’s clinical experience and professional status are typically viewed as career advantages, these may prevent staff from identifying their knowledge gaps and decrease their sense of urgency for incorporating new evidence into their clinical routines. Therefore, clinical experience and professional status may carry the risk for biased medical decisions in which staff make “the same mistakes with increasing confidence over an impressive number of years.”49
Although residents’ lack of clinical experience raises their awareness of their own information needs, they perceive their lack of clinical experience as a barrier to defining their clinical questions and to translating research evidence into the context of individual patients. Although residents regularly question current practice, their hierarchical dependence on staff for approval of their actions may hinder them in expressing their information needs and in introducing new evidence-informed clinical routines to staff. Therefore, encouraging safe communication and shared learning across career stages is perceived as the most prominent facilitator for EBM. In this way, staff and residents may benefit from each other’s strengths and learn from each other’s pitfalls.
Contribution to current knowledge
The focus of three prior reviews of qualitative studies on doctors’ perceptions of EBM has been on barriers to the uptake of evidence-based recommendations from CPGs.3–5 Carlsen et al3 explored the barriers to the uptake of CPGs by general practitioners. They reported in more detail on the dilemmas in combining the gatekeeper and patient advocate roles when proscriptive CPGs are perceived to cause rationing and denial of patients’ requests, thereby threatening the doctor–patient relationship. This corroborates our theme “Translating research evidence to individual patients.” Cochrane et al4 reported barriers to doctors’ uptake of CPGs and evidence. Saillour and Michel5 studied barriers and facilitators for the uptake of CPGs. A fourth review by van Dijk et al6 reported residents’ barriers to practicing EBM. They found that residents experienced specific barriers, such as being particularly vulnerable in professional settings with a strong pecking order. Although these four reviews used different classifications for barriers to EBM, their content substantially overlaps. All these barriers are present in our systematic review. We add to these reviews in that we explored patterns in the distribution of barriers and facilitators of EBM by comparing the descriptive themes across career stages, medical disciplines, practice settings, and time of study. In addition, our exploration of both barriers and facilitators may provide novel understanding of how to overcome the barriers by fostering the facilitators.
We have limited our search to qualitative studies. We have learned during preparing this manuscript that studies reporting frequencies of doctors’ opinions about barriers and facilitators for EBM are a vital source of information. Since these barriers and facilitators were synthesized and classified by Grol and Grimshaw,50 they have been further substantiated, most recently in a systematic review of surveys by Ubbink et al,51 but no major new barriers and facilitators have been revealed. We build on this information, but from the perspective of the thematic synthesis of qualitative data. In this our aim was to provide another viewpoint on the barriers and facilitators, adding to these studies by synthesizing the still-fragmented qualitative data.
Systematic reviews of qualitative data are very labor-intensive and require considerable expertise. We started with a comprehensive search in PubMed, as this is the most comprehensive source of health care literature. We realize that restriction of study retrieval from a single database may be suboptimal. Therefore, we decided in advance to proceed to searches in Embase, CINAHL, and other bibliographic databases, if conceptual saturation8,9 could not be reached with studies retrieved from PubMed. Our rigorous selection of studies and our explicit assessment of relevance and quality of methods (including the use of purposive or theoretical sampling to support conceptual saturation)8,9 resulted in 30 qualitative studies retrieved from PubMed. These studies included a very large number of individual doctors (n = 1,423) across a range of medical disciplines, career stages, and settings. We reached conceptual saturation based on the transparently extracted data from these 30 studies. Hence, we put trust in our data, and we consider it not very likely that inclusion of more data would change the findings from our thematic synthesis. Therefore, we proceeded with our thematic synthesis without further searches in other bibliographic databases.
Although we have reached conceptual saturation with the 30 included studies, the transferability of our findings to non-Western practice settings may be limited. First, of the 30 included studies, only 4 (13%) were conducted in non-Western practice settings. Second, by using a language filter for English articles during our PubMed search, we excluded 67 (5%) non-English articles. Of these 67 non-English articles, 60 (90%) were published in other European languages, 4 in Chinese, 2 in Japanese, and 1 in Russian. Subsequently, among the 1,211 retrieved PubMed publications, no other non-English full-text publications remained.
As in quantitative systematic reviews, extraction and coding of data can be subject to opinion and observer variation. To reduce such variation we first piloted study assessment for relevance and quality on five studies. Subsequently, we repeatedly discussed our coding of data to ensure similarity of interpretation and coding. We used a verifiable (transparent, explicit, and systematic) approach to secure consensus between research staff experienced in systematic reviews and/or qualitative methods.
Implications of the review
We have shown how qualitative studies can be synthesized, and we provide a novel understanding of the barriers and facilitators for the uptake of EBM in medical decision making. We found that doctors perceive that it is important to systematically reflect on clinical practice, to articulate information needs, to combine best research evidence with clinical experience, and to act accordingly. Moreover, learning by doing and interaction were shown to be central to medical practice, which makes poor collaboration an important barrier to the uptake of EBM. Poor collaboration makes residents vulnerable, and it also negatively affects staff, as this may hamper the exchange of information and discussion about medical decisions. Poor collaboration has also been shown to increase the risk for cognitive and affective biases in medical decision making, such as overconfidence.52–56 Moreover, doctors perceive safe communication and shared learning as strong facilitators for the uptake of EBM.
Conclusion and Recommendations
This thematic synthesis of qualitative studies has identified several important barriers and facilitators for EBM as perceived by doctors. Over the last decade, EBM teaching in medical curricula, residency training programs, and continuing medical education focused on EBM knowledge and skills. Our findings suggest that encouragement of collaboration by means of safe communication and shared learning across career stages will facilitate the uptake of EBM and reduce cognitive and affective biases in medical decision making. In their pursuit for answers to their information needs, residents should challenge staff’s clinical routines, while staff should use their clinical experience to guide residents to articulate their information needs and guide them in translating research evidence to individual patients. With equal contribution and involvement in collaboration, residents and staff may feel equally respected, and this may further contribute to the uptake of EBM and improve medical decision making.
Acknowledgments: The authors wish to thank Dragan Ilic (D.I.), senior lecturer from Monash University in Australia, and the biomedical student Danielle van der Waal (D.W.) from the University Medical Centre Utrecht in the Netherlands, for their contributions to the search and selection of studies. They did not receive any compensation.
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