Physicians' attitude toward evidence based obstetric practice: a questionnaire survey

British Medical Journal, Jan 31, 1998 by Olufemi A. Olatunbosun, Lindsay Edouard, Roger A. Pierson

Evidence based medicine integrates the best available data from clinical research into clinical practice to enhance the quality of clinical decisions and achieve the best possible outcome.[1 2] With a lack of awareness of relevant research, a substantial part of clinical practice in reproductive health relies on practitioners' personal experience, resulting in large variations in practice between healthcare workers.[3] The precise role of evidence based medicine is being debated; we therefore examined the awareness and views of medical practitioners with special emphasis on obstetric practice.

Subjects, methods, and results.

We mailed an anonymous, self administered, two page questionnaire to a random sample of 190 practitioners in obstetric practice between March and May 1996. The response rate of family physicians (120/154, 78%) and obstetricians (28/36,78%) was similar, as were the demographic characteristics of the urban and rural practitioners who responded. As expected, there were similar numbers of urban (63) and rural (57) family physicians, but only six rural obstetricians compared with 22 urban practitioners.

Overall, 113 (76%) of the 148 respondents were aware of evidence based medicine. However, 75 (51%) indicated that, when faced with a difficult clinical problem, they consulted a respected authority, 55 (37%) used a textbook or clinical practice guidelines, while only 12 (8%) conducted Medline literature searches. Fewer family physicians used Medline than did obstetricians (4 (3%) v 8 (29% P [is less than or equal to] 0.00 1). Forty (27%) respondents felt that they were very familiar with the critical appraisal of the medical literature, 31 (21%) were familiar with the use of computers in scientific inquiry, 42 (28%) had access to the internet, and only 14 (9%) indicated that they had access to the Cochrane Pregnancy and Childbirth database.[4] Although only 59 (40%) considered evidence based medicine to be very applicable to obstetric practice and another 56 (38%) thought it somewhat applicable, 130 (88%) expressed interest in learning more about it. Similar trends occurred for both family physicians and obstetricians.

Concerns about evidence based medicine were expressed through comments such as "erosion of physician autonomy," "scarcity of evidence in reproductive health," "it is time consuming," "obstetrics requires manual dexterity more than science," and "evidence based medicine ignores clinical experience."

Comment

Clinical decision making--which has until recently been based on pathophysiological principles, personal observation, and intuition--is shifting toward the artful application of systematically analysed results of scientific research.[5] Our study shows that personal experience and authoritarian views of experts still have an enormous influence in obstetric practice. Most practitioners in this survey were unfamiliar with the use of computers for accessing medical databases and with the critical appraisal of the literature. As most thought that evidence based medicine was only partially or not at all applicable to obstetric practice, we suggest that much scepticism prevails. Some of the views expressed may differ widely according to practice characteristics such as location or specialty, but these should be amenable to appropriate interventions.

The ability to evaluate the literature and apply methods of data analysis to procedural practice is an important aspect of medical education. This may be the most important skill that we can pass to the next generation of medical practitioners. The dividing line between the science and art of medicine is not as distinct as we would wish with clinical decision making in reproductive health. Evidence based medicine should enhance doctors' competence through the integration of important evidence from research, moder-ated by experience, into clinical care. The views expressed by doctors in this study reflect obstacles to evidence based practice, which should be tackled through changes to training and access to resources.

Contributors: OAO, the principal investigator and guarantor of the study, conceived the research idea and coordinated the study as well as designing the questionnaire with substantial contributions from LE and RAP, who also provided statistical advice and participated in data analysis and preparation of the manuscript.

Funding: None.

Conflict of interest: None.

[1] Knottnerus JA, Dinant GJ. Medicine based evidence, a prerequisite for evidence based medicine. BMJ 1997;315:1109-10.

[2] Olatunbosun OA, Edouard L The teaching of evidence-based reproductive health in developing countries. Int J Gynecol Obstet 1997;56:171-6.

[3] Grimes D. Technology follies: the uncritical acceptance of medical innovation. JAMA 1993;23:3030-3.

[4] The Cochrane Database of Systematic Reviews. The Cochrane Library. Cochrane Collaboration; Issue 2. Oxford: Update Software, 1996.

[5] Evidence-based medicine, in its place. Lancet 1995;346:785.

Department of Obstetrics and Gynaecology, College of Medicine University of Saskatchewan, Saskatoon, Saskatchewan, S7N OW8 Canada