No abstract

Decision making about anticoagulation is complex and is determined by a socially constructed view of the evidence strongly influenced by the GP's professional role.

GPs are seen as having less expert power than consultants and to be more compliant with externally managed guidelines and audit programmes. It is pointed out that compliance with guidelines and audit programmes helps GPs to meet their contractual requirement to be involved in clinical audit activities. Evidence-based practice, which directly challenges the authority of expert opinion is seen as a threat to the power of consultants, but a potential opportunity for GPs and other clinicians whose status is traditionally lower.

This paper explores some of the issues raised by the finding in a randomized controlled trial (RCT) that general practitioners (GPs) taking part failed to use a computerized evidence-based guideline, nor did it have any impact on patient outcomes. GPs are expected to 'make an initial decision on every problem [patients] may present' and to address psychological and social problems in addition to biomedical ones. The computerized guideline imposed an external, largely biomedical, agenda that superseded the patient's. This disrupted the normal pattern of GP consultations and it was therefore ignored. Guidelines for any particular disease are effective if backed up by a detailed programme of education and audit. However, the large number of different conditions seen in general practice means that it is impractical to have such programmes for more than a small fraction of the clinical workload. The reductionist assumptions underlying the construction of evidence-based guidelines from systematic reviews lead to inflexible recommendations on the management of disease. Anthropologists and sociologists make an important distinction between scientifically defined diseases and the culturally constructed experience of illness. Because GPs deal with patients suffering illness that may or may not result from disease, disease-centred guidelines often conflict with their needs and wishes. The development of evidence-based medicine (EBM) was intended as a tool to help doctors make sense of evidence in the context of individual patients' problems. Few GPs are skilled in it, and it has been appropriated by powerful expert groups such as guidelines developers and the pharmaceutical industry. It is suggested that more understanding of EBM by GPs leads to better informed decision making by them and their patients.

Objectives To describe a group general practice's implementation of a decision to prescribe 3 day courses of 200 mg trimethoprim twice daily for urinary tract infections in women and to compare 3 day courses with 5 and 7 day courses. Design Record review, audit of trimethoprim prescribing for urinary tract infections, and critical appraisal of evidence originally presented in support of 3 day course. Setting Group general practice in Newcastle upon Tyne. Data sources The records of all female patients aged 12 years and older who were prescribed trimethoprim for uncomplicated urinary tract infections during a 12 month period were reviewed. 271 valid records were identified. Data extraction Prescribing rates for different courses of trimethoprim, rates of patients returning for second consultations, rates of urine cultures, results of cultures, results of critical appraisal of evidence. Results 114 of 271 (42%) prescriptions written at the first visit were for 3 day courses. 16 of 114 (14%) patients who had had a 3 day course of treatment returned for a second consultation compared with 6/83 (7.2%) of those who had had a 5 day course and 8/74 (11%) who had had a 7 day course. The difference between 3 day and 5 day courses in rates of returning for second consultations was 6.8% (95% CI − 1.7% to 12.6%) and between 3 day and 7 day courses was 3.2% ( − 3.6% to 10.0%). Appraisal of the original evidence on which the practice based its recommendations showed that it was flawed. Additional evidence was found in the Cochrane Library. Conclusions Our original decision, made by consensus at a meeting of the practice's partners, had not led to a consistent change in practice. We did not find a significant increase in treatment failures among patients treated with the 3 day regimen.