| Project Objectives / Summary:
Evidence based medicine (EBM) is more likely to be enthusiastically adopted by GPs when it is owned and directed by them. Mackay Division of General Practice (Queensland) during-1999 - 2001 instigated this successful innovative EBM project and it has shown that GPs in regional Australia have a significant interest in the application of EBM to their clinical practice.
Initially developed as a pilot study to assess the feasibility of models for promotion, workshop delivery, uptake and sustainability of the practice of EBM in general practice, the project was later expanded and developed into grass roots practical forums in 2001. The project has shown a strong demonstrated capacity for sustainability beyond the life of the project because many GPs are committed to building EBM into their everyday clinical practice.
In the first phase of the project a range of evidence based workshops were conducted in six Divisions throughout Queensland by an academic GP with considerable expertise and an international reputation in EBM. 96 GPs attended the workshops overall and provided GPs with a practical background in the terminology and methods of evidence based medicine. Resource kits were distributed to GP practices and Divisions across Queensland. Follow-up services in the form of a Literature Search Service, a Single Patient Trials service, EBM teleconferences and email discussion lists were delivered. Many GPs completed Introductory, Advanced and Intensive workshops on EBM across urban and rural Queensland.
During Phase Two four peer group discussion meetings were developed and conducted over a period of four months in Mackay. Bendigo also completed four meetings over a period of three months. An evaluation of participation from both areas was completed and showed an overwhelming strong interest from GPs and a willingness to continue meeting to focus on EBM in the longer term.
The Mackay meetings were planned and conducted by a GP facilitator with extensive experience in evidence based medicine principles. In Mackay a total of 64 GPs attended the four sessions. In the Bendigo there was a total of 40 GPs who attended the four sessions.
James Cook University School of Medicine academic educators attended the final meeting in Mackay to encourage further research collaboration activities. The University remains committed to working with local GPs to support this interest in EBM being expanded out to support a broader GP interest in clinical research.
Aims and Objectives
The principle aim of the project was to encourage GPs to collaborate with one another and discuss the application of evidence based medicine, ensuring better patient outcomes through improved clinical decision making.
The supplementary activities of this project were aimed at building a model that established that EBM could become an on-going activity that GPs utilised in their practices with the support of their colleagues
Project Outcomes:
Following the introduction of GPs to evidence based medicine principles through a series of workshop throughout Queensland during 2000 (Phase One), it was identified that further reinforcement of practical EBM techniques was required in order to encourage its incorporation in everyday clinical situations. A number of GPs in the Mackay Division had also expressed a further interest in developing a research interest group. A proposal to promote clinical EBM discussion groups to encourage the establishment of sustainable supported peer learning environments was developed to address these issues.
Despite the fact that many Mackay GPs attended Introductory workshops in Evidence based medicine during 2000 with the University of Queensland and Mackay Division of General Practice, the Peer group sessions were designed on the basis of little or no knowledge by participating GPs of evidence based medicine principles. The four sessions represented a practical introduction to EBM for those GPs who had little or no prior experience.
Research
Interest, knowledge and ability to participate in research activities was one of the components of the project that was analysed. Three of the participating GPs in the pre project planning meeting expressed their interest in participating in research activities through the implementation of a Research Interest Group within the Mackay Division of General Practice.
In order to determine the level of skill and interest of the participating GPs in research activities, questions relating to this were proposed in both the pre survey and RACGP CME evaluation.
In the pre survey it was found that 61.5% of the 21 GP participants had never taken a course in research methodology or statistics. The remaining 38.5% had undertaken courses in the past. Of the 14 GPs completing the RACGP CME evaluation, eight GPs answered affirmatively to being a participant in the Research Interest Group being implemented and indicated that the EBM sessions had stimulated an interest in research activities.
The final meeting in Mackay allowed the opportunity for representatives from the James Cook University to address GP participants about the possibilities for collaboration in any future research activities being undertaken by Division GPs.
Phase One - Summary
The workshops were seen as a useful activity demonstrating a "valued clinical tool" and raising awareness of Internet searching. Overall, Internet searches were seen as an additional tool for gathering information rather than an alternative tool. Little change in clinical practice was reported.
Perceptions about Evidence Based Medicine
The main barriers to using Internet technology were:
- Time;
- Skills;
- Confidence; and
- Familiarity.
Strengths of Evidence Based Medicine
Participants were pleased to incorporate information which is critically presented and has been evaluated, into judgements based on their own experience.
Barriers to using Evidence Based Medicine
Some participants lacked the confidence and/or skills in critical analysis of data presented.
Some participants reported preferring to base decisions on guidelines, journal article that presents only one viewpoint, rather than having to analyse
Decision making behaviour of General Practitioners and patients
The focus group discussions highlighted opposing beliefs by individual General Practitioners. One General Practitioner stated that patients "don't want the options" while another thought that some patients were interested in being presented with options and evidence. The latter GP felt that it was necessary to "keep trying".
Evidence Based Medicine Workshops
Strengths of the workshops
A number of benefits of attending the workshops were highlighted. The workshops were reported to have demonstrated that evidence based medicine and Internet searches are "valued clinical tools", and to have increased the ability of participants to practice evidence based medicine
Participants reported an overall increase in their confidence with using computer search tools, an increase in awareness of Cochrane and an increase in managing information needs.
Weaknesses of the workshops
No discussion was reported about weaknesses of the workshops.
Changes in clinical practice
Overall, little change in clinical practice was reported as a result of the evidence based medicine workshops.
It was noted that General Practitioners might change their clinical practice over time in response to evidence presented which indicates the benefits of new treatment practices
Some general practitioners reported a general interest in information ~ through the Internet ("intellectual curiosity") rather than a desire to obtain in which could be used in treatment decisions for a particular patient. Other GPs reported using the Internet most often in relation to a particular patient.
Internet Searches
Strengths of Internet searches
A number of strengths of Internet searches were raised:
- "a much better tool than trying to look up journals or ringing specialists";
- "Don't read much at times";
- The Internet can provide information on rare conditions, give new evidence support general practitioners (particularly when making clinical decisions); and the Internet has great potential but "EBM is embryonic in its influence";
- Some General Practitioners reported that they accessed literature searches as additional source of information, rather than an alternative source of information. This appeared to be an attempt at triangulation by these general practitioners.
Barriers to conducting Internet searches
- Lack of skills in asking the "right questions";
- Confidence in using the technology;
- Lack of success in conducting searches;
- GPs not willing to conduct searches in front of their patients (either because of their lack of confidence in using the computer, lack of time, or not wanting to lose credibility with their patient) and did not have time later to conduct searches;
- Did not have access to the Internet;
- Reliability of the site;
- Lack of motivation; and
- Cochrane is "too complicated".
Generally, there appeared to be a lack of familiarity with the Literature Search Service even though it had been available free of charge and required a minimal amount of time
Barriers to using the Literature Search Service.
- Disappointment with the results of searches because either the question was too broad, or there was no evidence available;
- Unsure of how the forms worked or lacked familiarity with the service (that is, how it works and how long it takes to receive an answer back);
- Time - difficult to find "even ten minutes in the surgery" to complete forms although discussion was equivocal on the role of cost in whether or not a genera practitioner would use the evidence based literature search service, cost may be (barrier in the future if General Practitioners are required to pay for searches);
- Need to have a specialist interpret the evidence; and
- It was noted that government incentives are paid to encourage practices to computerise but there are no incentives for practices to ensure that General Practitioners and staff are trained adequately to use the technology available.
Email discussion group
No General Practitioner reported having used the discussion group. However, one GP independently raised the issue of the benefits of General Practitioners sharing knowledge.
Particular barriers to use of the email discussion group were:
- Lack of access to appropriate technology;
- Lack of confidence with computers;
- Lack of time;
- Lack of understanding about the purpose of the discussion group;
- Lack of personal contact ("I would rather talk to my colleagues"); and
- Lack of ability to touch type.
Summary Phase Two
The principle aim of the project was to encourage GPs to collaborate with one another and discuss the application of evidence based medicine, ensuring better patient outcomes through improved clinical decision making. From the results of the data analysis it can be deduced that evidence based medicine peer group discussions have had some positive effects on participant's knowledge, skill, behaviour and attitude in regard to EBM.
From the results attained, participants indicated that the opportunity to discuss clinical information and case studies with peers was a valuable result of attending. The utilisation of peers as an informational resource and the ability to network with peers in a clinical practice environment was also perceived as particularly beneficial. Many participants indicated that they are now more able to make knowledgeable decisions regarding patient care. Therefore, we can infer that GP collaboration and the discussion of the application of evidence based medicine was well met by attendance at EBM case based discussion meetings.
Attendance at EBM groups seems to have increased participants skill level in accessing evidence, appraising evidence and applying the evidence found to a clinical practice setting. As a result of this, many believe that their patient care will improve and the information disseminated to patients will be more useful and up to date. As a result of attending EBM discussion groups, we can infer that the skill level of participants notably increased and that GPs are now in a position to provide enhanced patient care through improved clinical decision making.
A positive attitude toward the value of clinical evidence when making clinical decisions was fostered as a result of the meetings. As a result of this, the number of participants willing to disseminate clinical based information to their peers has also increased. The attitude concerning the utilisation of specialists and peers for clinical based information was also enhanced.
This project has proved to us that EBM interactive discussion groups can be successful at a "non-academic" GP level. The higher than expected attendance levels and vote to continue the meetings both confirm the support and approval of this style of EBM meeting by local GPs.
GP participants at the final session indicated in the majority their preference for continuing case based discussion groups on a monthly basis under the facilitation of the GP who conducted the EBM discussion groups. GP participants were satisfied with the format of these discussion groups as it provided the ideal forum for clinical based discussion with peers in the Mackay Division. The ability to provide more hands on technical expertise wasn't within the scope of the project and would be advantageous for future evidence based medicine workshops.
Previous research has shown that GPs tend to learn more from an interactive small group setting, than from formal lecture presentations. In this instance, the GP facilitator probably learnt the most during the four sessions, because she was the main individual doing the EBM research for the meetings. In view of this, for future meetings, all the participating GPs have agreed to take it in turns to present EBM research, based on their own clinical questions. This will increase the learning capacity of the group as a whole, and ensure the discussion revolves around issues important to everyday clinical practice; that is "EBM -by GPs, for GPs." As a bonus, these EBM meetings are also likely to stimulate ideas for future "grass-roots".
Recommendations:
Recommendations provided by participants of the focus group discussions:
- Need for more experience in use of the technology and better access to appropriate technology;
- Provision of additional training to improve knowledge of "how to actually put the question";
- Expanding evidence based medicine provision of information in the BMJ Clinical Evidence handbook "that's very easy to access and much quicker to just look up an index than the computer";
- Making Internet sites easy to search;
- Workshops should "explain how to use the search engines faster", and provide skills at phrasing questions, how the database works, and Boolean logic;
- Participants asked about follow-up workshops and including information clinical epidemiology; and
- One participant recommended putting the literature search service form into an email format with an easy access icon from, say, Medical Director.
Disseminating Project Information:
Resources:
- Four PowerPoint presentations have been produced and are available to relevant organisations upon request.
- A GP desktop guide is available in hardcopy and a list of relevant Internet sites is available.
- Resource material relating to a number of therapeutic topics and researched case studies was compiled and distributed to participating GPs in both Divisions in kit form.
Publications:
- QDGP Newsletter, January 2000
- Poster Presentation, National Divisions Forum, Brisbane, August 2000
Lessons:
Evaluation of the project provided information on the barriers to uptake of EBM in general practice and disappointingly there were smaller than expected numbers of participating GP's in the first phase of the project. After consultations with GPs, the Mackay Division of General Practice (Queensland) found that the limitations on the take-up of EBM were linked to the need to make the EBM activities more practical. The EBM project was therefore refocused to provide resources and support which enabled local groups of GPs to engage in self directed EBM activities which meant these were instigated from regular clinical practice and more importantly incorporating local knowledge drawn from their GP peers. |
