The discomfort of an evidence-based prescribing decision

Prescribing decisions are not always based on published clinical research; social and environmental influences can sometimes drive such decisions. However, little is known about this topic in prescribing in secondary care. The aim of this study was to explore such influences by asking doctors to discuss their uncomfortable prescribing decisions in secondary care.

Forty-eight doctors, of varying grades from four hospitals, were selected for in-depth qualitative interviews, which included the critical incident technique. Doctors were asked to remember any uncomfortable prescribing decisions and these 'incidents' were discussed, enabling the researcher to unpack the more subconscious influences on the decision to prescribe. Interviews were tape-recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.

All doctors had previously been uncomfortable when attempting to practise in accordance with evidence-based medicine. Locating, critically appraising and applying the evidence to individual patients were frequent causes of discomfort. Many doctors struggled with uncomfortable decisions that were influenced by non-research evidence, such as prior experience or expert opinion. This appeared, in part, because of these doctors' skewed notions that EBM condemns clinical experience as illegitimate evidence.

Incorporating the research evidence into prescribing decisions was associated with much discomfort by secondary care doctors. Greater efforts should also be placed towards developing the model of EBM, so that it fits more explicitly with how medicine is currently practised. Perhaps more importantly, educators need to reinforce what EBM is and what it is not to all concerned in the delivery of health care.