Family Practice Vol. 17, No. 5, 428-429
© Oxford University Press 2000
Discussion paper |
A preliminary study of the decision-making process within general practice
Department of Epidemiology and Public Health, Institute of Child Health, Great Ormond Street Hospital, 30 Guilford Street, London WC1N 1EH and
a Research Development Support Unit, Postgraduate Medical School, University of Exeter, Exeter, UK.
Mears R and Sweeney K. A preliminary study of the decision-making process within general practice. Family Practice 2000; 17: 428–429.
Received 4 November 1999; Revised 6 April 2000; Accepted 16 May 2000.
Abstract
Objective. The aim of the present study was to explore the factors that contribute to the process of decision making within general practice, over and above evidence-based information.
Methods. A qualitative study was conducted using semi-structured interviews on a purposeful sample of GPs, based in the South West of England. Each interview was tape-recorded and transcribed verbatim.
Results. Five broad categories emerged from the data: practitioner; patient; practitioner–patient relationship; verbal and non-verbal communication; evidence-based medicine; and external factors.
Conclusion. The nature of general practice is such that the process of making clinical decisions is complex. In an era when GPs are being overwhelmed by evidence-based information, consideration needs to be given to the implications that the nature of the decision-making process has upon the way ‘evidence’ is constructed and promoted within general practice.
Keywords. Clinical decision making, decision making, evidence-based medicine, general practice, GP.
Introduction
Defined as the "conscientious, explicit and judicious use of current best evidence",1 evidence-based medicine (EBM) has emerged as a new paradigm for medical practice. Awareness of the latest scientific evidence, the ability critically to appraise literature and assess the generalizability have been identified as integral to the practice of EBM. However, the evaluation of evidence within general practice is often illogical and irrational2 and it cannot be assumed that GPs practise the principles underpinning EBM in their decision making.
The purpose of this study was to conduct a preliminary investigation of the factors that contribute to the clinical decision-making process within general practice, over and above the assumptions underlying evidence-based information.
Methods
Semi-structured interviews were conducted using a ‘convenient’, purposeful sample of GPs, who were either based in a research-based general practice or involved in continuing medical education.
Data collection
RM conducted semi-structured interviews with each practitioner for ~1 hour. Each GP gave both their written and verbal consent. Interviews were audio-taped and transcribed verbatim and, to ensure reliability, each transcript was read independently by RM and another researcher who was blinded to the study aims. Their results were compared in order to establish a degree of congruence and disparity. A degree of congruence of 80% was deemed acceptable.4 Respondent validation was also used to ensure that the data analysis and interpretation were an accurate reflection of the views of the practitioners.
Results and discussion
All five practitioners were based in practices within the South West of England. One of the practitioners was female. Their mean age was 47 years (range 40–54 years), and three of the practices were training practices.
The results indicated five broad categories that contribute to the decision-making process within general practice: practitioner; patient; practitioner–patient relationship; communication; EBM; and external factors.
Practitioner
All of the practitioners described that previous clinical experiences, and their own philosophy of health and clinical beliefs had an impact upon clinical decision making: "doctors also have their own philosophy of health, and there's no reason why they shouldn't..." (Interview 1), and "it's the things that go wrong that imprint on your memory..." (Interview 3).
Patient
Among all respondents, there was also recognition that understanding patients' cultural beliefs, background and attitudes is integral to the decision-making process: "you have to respect their beliefs and values..." (Interview 5), "you have to know where the patients are coming from... and what their beliefs are" (Interview 1).
Practitioner–patient relationship
Respondents all referred to the importance of maintaining good relations with patients: "... patients are technicolour and actually the relationship is technicolour" (Interview 1). One practitioner described a situation in which he had bowed to the expectations of the patient for the sake of maintaining good relations: "the nature of the relationship is one that continues and goes on and there may be far more important issues coming up than this trivial issue of whether or not you prescribe penicillin..." (Interview 1).
Verbal and non-verbal communication
All of the respondents mentioned being aware of the language that they used during a consultation: "you've got to pitch what you say at a level that the patient will understand..." (Interview 3). Two respondents cited non-verbal cues as informing the clinical decisions that they made, e.g. whether or not to prescribe: "patients do give quite strong messages without necessarily expressing them verbally, about what they want" (Interview 1).
Evidence-based medicine (EBM)
There was a pervading feeling among respondents that the EBM approach to clinical decision making did not allow for the complexities inherent within the decision-making process in general practice: "only a proportion of clinical decision making is ever to do with research..." (Interview 4), "... EBM measures the things that can be measured..." (Interview 2).
External factors
Time, cost and the media were three factors extraneous to the practitioner and patient most commonly cited as influencing the decision-making process: "GPs are conscious of society's views but particularly cost..." (Interview 3), "time is critical, we don't have very long, that's the problem" (Interview 5), "... the media are more powerful than anything else" (Interview 5).
Study limitations
Due to both time and financial constraints, the sample size in this study was very small. This factor represents a major limitation for this study; the results are therefore presented as preliminary.
Conclusion
The findings of this preliminary investigation suggest, in support of previous studies,3,5 that the approach to clinical decision making within general practice is multi-faceted. The complexities inherent within this process are not reflected in the ‘linear’ approach of formulating a clear clinical question, promoted within the EBM model.1
In an era when GPs are being overwhelmed by evidence-based information, consideration needs to be given to the implications that this has upon the way in which ‘evidence’ is constructed and presented to GPs. Any evidence-based model aimed at general practice needs to be compatible with its complex, and often irrational, illogical nature.
References
1 Sackett DL, Richardson WS, Rosenberg W, Haynes BR. Evidence-based Medicine—How to Practice and Teach EBM. Churchill Livingstone, 1997.
2 Sweeney K, MacAuley D, Pereira Gray D. Personal significance—the third dimension. Lancet 1998; 351: 134–136.[Web of Science][Medline]
3
Tomlin K, Humphrey C, Rogers S. General practitioners' perceptions of effective health care. Br Med J 1999; 318: 1532–1535.
4 Miles MB, Huberman AM. Qualitative Data Analysis. 2nd edn. Thousand Oaks, CA: Sage, 1994.
5 Jacobson LD, Edwards AGK, Granier SK, Butler CC. Evidence-based medicine and general practice. Br J Gen Pract, 1997; 47: 449–452.[Web of Science][Medline]
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