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Simons M, Fisher G, Spanos S, Zurynski Y, Davidson A, Stoodley M, Rapport F, Ellis LA. Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants. BMC MEDICAL EDUCATION 2024; 24:418. [PMID: 38637798 PMCID: PMC11027546 DOI: 10.1186/s12909-024-05409-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND In the past, evidence-based medicine (EBM) and shared decision-making (SDM) have been taught separately in health sciences and medical education. However, recognition is increasing of the importance of EBM training that includes SDM, whereby practitioners incorporate all steps of EBM, including person-centered decision-making using SDM. However, there are few empirical investigations into the benefits of training that integrates EBM and SDM (EBM-SDM) for junior doctors, and their influencing factors. This study aimed to explore how integrated EBM-SDM training can influence junior doctors' attitudes to and practice of EBM and SDM; to identify the barriers and facilitators associated with junior doctors' EBM-SDM learning and practice; and to examine how supervising consultants' attitudes and authority impact on junior doctors' opportunities for EBM-SDM learning and practice. METHODS We developed and ran a series of EBM-SDM courses for junior doctors within a private healthcare setting with protected time for educational activities. Using an emergent qualitative design, we first conducted pre- and post-course semi-structured interviews with 12 junior doctors and thematically analysed the influence of an EBM-SDM course on their attitudes and practice of both EBM and SDM, and the barriers and facilitators to the integrated learning and practice of EBM and SDM. Based on the responses of junior doctors, we then conducted interviews with ten of their supervising consultants and used a second thematic analysis to understand the influence of consultants on junior doctors' EBM-SDM learning and practice. RESULTS Junior doctors appreciated EBM-SDM training that involved patient participation. After the training course, they intended to improve their skills in person-centered decision-making including SDM. However, junior doctors identified medical hierarchy, time factors, and lack of prior training as barriers to the learning and practice of EBM-SDM, whilst the private healthcare setting with protected learning time and supportive consultants were considered facilitators. Consultants had mixed attitudes towards EBM and SDM and varied perceptions of the role of junior doctors in either practice, both of which influenced the practice of junior doctors. CONCLUSIONS These findings suggested that future medical education and research should include training that integrates EBM and SDM that acknowledges the complex environment in which this training must be put into practice, and considers strategies to overcome barriers to the implementation of EBM-SDM learning in practice.
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Affiliation(s)
- Mary Simons
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia.
- Australian Institute of Health Innovation, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia.
| | - Georgia Fisher
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Samantha Spanos
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Andrew Davidson
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Marcus Stoodley
- Department of Clinical Medicine, Macquarie University, Sydney, NSW, 2109, Australia
| | - Frances Rapport
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
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Leidel S, McConigley R, Boldy D, Wilson S, Girdler S. Australian health care providers' views on opt-out HIV testing. BMC Public Health 2015; 15:888. [PMID: 26369954 PMCID: PMC4570459 DOI: 10.1186/s12889-015-2229-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/04/2015] [Indexed: 12/03/2022] Open
Abstract
Background Opt-out HIV testing is a novel concept in Australia. In the opt-out approach, health care providers (HCPs) routinely test patients for HIV unless they explicitly decline or defer. Opt-out HIV testing is only performed with the patients’ consent, but pre-test counselling is abbreviated. Australian national testing guidelines do not currently recommend opt-out HIV testing for the general population. Non-traditional approaches to HIV testing (such as opt-out) could identify HIV infections and facilitate earlier treatment, which is particularly important now that HIV is a chronic, manageable disease. Our aim was to explore HCPs’ attitudes toward opt-out HIV testing in an Australian context, to further understanding of its acceptability and feasibility. Methods In this qualitative study, we used purposeful sampling to recruit HCPs who were likely to have experience with HIV testing in Western Australia. We interviewed them using a semi-structured guide and used content analysis as per Graneheim to code the data. Codes were then merged into subcategories and finally themes that unified the underlying concepts. We refined these themes through discussion among the research team. Results Twenty four HCPs participated. Eleven participants had a questioning attitude toward opt-out HIV testing, while eleven favoured the approach. The remaining two participants had more nuanced perspectives that incorporated some characteristics of the questioning and favouring attitudes. Participants’ views about opt-out HIV testing largely fell into two contrasting themes: normalisation and routinisation versus exceptionalism; and a need for proof versus openness to new approaches. Conclusion Most HCPs in this study had dichotomous attitudes toward opt-out HIV testing, reflecting contrasting analytical styles. While some HCPs viewed it favourably, with the perceived benefits outweighing the perceived costs, others preferred to have evidence of efficacy and cost-effectiveness. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2229-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stacy Leidel
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
| | - Ruth McConigley
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
| | - Duncan Boldy
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
| | - Sally Wilson
- School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
| | - Sonya Girdler
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
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Swennen MHJ, van der Heijden GJMG, Boeije HR, van Rheenen N, Verheul FJM, van der Graaf Y, Kalkman CJ. Doctors' perceptions and use of evidence-based medicine: a systematic review and thematic synthesis of qualitative studies. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:1384-96. [PMID: 23887011 DOI: 10.1097/acm.0b013e31829ed3cc] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
PURPOSE Many primary qualitative studies of barriers and facilitators for doctors' use of evidence-based medicine (EBM) are available, but knowledge remains fragmented. This study sought to synthesize the results of these qualitative studies, taking the variability across context (i.e., medical disciplines, career stages, practice settings, and time of study) into account. METHOD The authors searched PubMed through April 26, 2012, and independently selected studies according to prespecified criteria for relevance and methodological quality. Additionally, they performed a thematic synthesis through line-by-line interpretation, coding, and thematic arrangement of information. RESULTS The search resulted in 1,211 publications, of which 30 studies were included. Five major themes emerged on barriers and facilitators for doctors' use of EBM: individual mind-set, professional group norms, EBM competencies, balance between confidence and critical reflection, and managerial collaboration. The authors found particular barriers and facilitators across career stages. Although clinical experience and professional status were perceived to be helpful, they could also prevent doctors from identifying information needs and adopting new evidence. Although residents' lack of clinical experience raised awareness of information needs, residents perceived lack of clinical experience and their hierarchical dependence on staff as barriers to articulating information needs and to translating and introducing evidence to patient care. CONCLUSIONS Encouragement of group norms for safe communication and shared learning across career stages is perceived as the most prominent facilitator for EBM.
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Affiliation(s)
- Maartje H J Swennen
- Department of Clinical Epidemiology, Division Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Abstract
There is much variation in the implementation of the best available evidence into clinical practice. These gaps between evidence and practice are often a result of multiple individual decisions. When making a decision, there is so much potentially relevant information available, it is impossible to know or process it all (so called 'bounded rationality'). Usually, a limited amount of information is selected to reach a sufficiently satisfactory decision, a process known as satisficing. There are two key processes used in decision making: System 1 and System 2. System 1 involves fast, intuitive decisions; System 2 is a deliberate analytical approach, used to locate information which is not instantly recalled. Human beings unconsciously use System 1 processing whenever possible because it is quicker and requires less effort than System 2. In clinical practice, gaps between evidence and practice can occur when a clinician develops a pattern of knowledge, which is then relied on for decisions using System 1 processing, without the activation of a System 2 check against the best available evidence from high quality research. The processing of information and decision making may be influenced by a number of cognitive biases, of which the decision maker may be unaware. Interventions to encourage appropriate use of System 1 and System 2 processing have been shown to improve clinical decision making. Increased understanding of decision making processes and common sources of error should help clinical decision makers to minimize avoidable mistakes and increase the proportion of decisions that are better.
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Affiliation(s)
- Louise Bate
- National Institute for Health and Clinical Excellence, Medicines and Prescribing Centre, Liverpool, United Kingdom.
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Swennen MHJ, van der Heijden GJMG, Blijham GH, Kalkman CJ. Career stage and work setting create different barriers for evidence-based medicine. J Eval Clin Pract 2011; 17:775-85. [PMID: 20438602 DOI: 10.1111/j.1365-2753.2010.01435.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Although many barriers to practising evidence-based medicine (EBM) are described, it remains poorly understood why clinicians do, and do not, incorporate high-quality evidence into their routine practice. To date, a comprehensive framework for the classification for barriers to practising EBM is lacking. This qualitative study explored the relationship between differences in career stage and work setting among doctors and their perceived barriers for practising EBM. We also explored an alternative classification of barriers. METHODS Purposive participant sampling reflected three career stages in two different work settings: four registrars, four consultant anaesthetists and four senior anaesthetists from two departments of anaesthesiology, in an academic and a general hospital, in The Netherlands. Perceptions on practising EBM and its barriers were explored in semi-structured interviews. Using grounded theory approach, we build a framework for the classification of these barriers. RESULTS In both departments, registrars and consultants demonstrated little sense of urgency to work on their EBM performance; registrars struggled with information overload and hierarchical dependence, and consultants practised confidence-based medicine. Senior doctors in both departments reported that combining clinical work with leadership tasks made them more reflective, and therefore more susceptible to the reasoning approach inherent within the current approach to EBM. They considered themselves willing and able to apply EBM, and were reported to act accordingly. Differences in setting that complicated practising EBM related to the general hospital. The absence of formal hierarchy among doctors resulted in a lack of medical consensus and an absence of integrated management teams hindered collaboration between doctors and non-medical managers. We identified 10 conditions that were conducive to the practice of EBM. CONCLUSIONS Both career stage and work setting were associated with perceived barriers to practising EBM. We have included these in our theoretical framework for classification of these barriers.
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Affiliation(s)
- Maartje H J Swennen
- Department of Clinical Epidemiology, Division Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
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