Abstract
A facility-based cross sectional study was carried out among 188 doctors working at the Kasturba Medical College in Mangalore, India, to assess the perception and practice of evidence based medicine (EBM) among medical professionals. Data was collected using a pre-tested questionnaire and results obtained were expressed in percentages. Results: The mean age of participants was 35 ± 8.33 years. A higher proportion of participants (n=182, 96.8%) referred to textbooks for information for clinical decision making. A majority of the participants (n=180, 95.8%) opined that evidence based medicine should be included in a medical curriculum. More than half of the participants (n=98, 52.1%) used PubMed. A majority (n=150, 79.8%) of the participants had a good level of self-rated confidence in evaluating research, while 55.3% (n=104) of the participants had a good level of self-rated confidence in their ability to conduct clinical appraisals. Lack of time and insufficient EBM skills were the major perceived barriers to practicing evidence based medicine. Conclusion: Positive attitudes and higher awareness regarding EBM among doctors in the present study compared to other reported literature is an encouraging finding. Medical regulators must utilize the best available evidence and experience in formulating policy on medical education and health care.
Keywords:
Introduction
Evidence based medicine (EBM) is gaining importance in the practice of medicine. EBM is defined as the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients…Integrating individual clinical expertise with patient values and the best available external clinical evidence from systematic research.”1 The concept of EBM was advanced by Professor Archie Cochrane and was later applied by David Eddy and David Sackett. Further, it was encouraged by the establishment of the Cochrane center in Oxford, England, by the government of the United Kingdom (UK).2
While the application of EBM was viewed skeptically initially, the scenario has changed in recent times, with the practical utility of EBM now well documented. Knowledge regarding certain therapies has increased significantly, and some that were used extensively have been recognized as unworthy or hazardous.3
Previously, management of clinical cases depended mainly on the clinical experience of doctors and their knowledge regarding disease. The norm was to consult local experts or textbooks to solve clinical problems. Today these are not considered reliable, as evidence may be lacking and information may be out of date.4
Clinical practice has become more scientific and systematic with the introduction of EBM.5 The main goal of EBM is to provide the best care possible to patients.6,7 Several measures have been accomplished in this regard, such as instituting Cochrane collaboration, setting up publication standards for primary and secondary research, and building a knowledge base and infrastructure for guidelines development, both nationally and internationally.5 The importance of EBM in general practice has been highlighted in recently reported literature.6,7 EBM also helps doctors in making better clinical decisions by providing updates regarding recent advancements through an organized and structured approach of medical education.8
WHILE THE APPLICATION OF EBM WAS VIEWED SKEPTICALLY INITIALLY, THE SCENARIO HAS CHANGED IN RECENT TIMES, WITH THE PRACTICAL UTILITY OF EBM NOW WELL DOCUMENTED.
The gap in implementation of results in clinical trials and their utility in case management results in costly and incompetent treatment.4 A majority of studies have shown that, though doctors have an optimistic attitude towards EBM, there is less awareness regarding its implementation.9–11 Few studies have been published on the perception of EBM among doctors, especially from developing countries such as India.
In view of the paucity of literature, the current study focused on determining the perception and practice of EBM among medical professionals in South India.
Methodology
Study setting
Mangalore is one of the three coastal districts of Karnataka in South India. The health care system in Mangalore is largely privatized, with the presence of six private medical colleges and many private clinics. Kasturba Medical College (KMC), Mangalore is a renowned institution and actively promotes research.
Study design
A facility-based cross-sectional study was carried out among doctors at three tertiary care teaching hospitals associated with KMC, Mangalore.
Sample size estimation
The sample size was calculated assuming that 50% of health care professionals were aware of EBM. Considering a relative precision of 15% and Confidence Interval of 95%, sample size was found to be 171. Adding a non-response rate of 10%, the final sample size was calculated to be 188.
Sampling technique
A list of all the doctors working in the targeted hospitals was obtained (400), and the participants were divided into two groups: surgical (105) and medical specialties (83). The required number of participants in each group was selected by using a probability-proportional-to-size method.
Ethical consideration
Ethical approval was obtained from the Institutional Ethics Committee (IEC) of Kasturba Medical College, Mangalore, India (affiliated with Manipal University), prior to commencement of the study.
Study instrument
Data collection was achieved using a pre-tested, semi-structured questionnaire modified from the questionnaire developed by McColl et al 11 after obtaining written informed consent from the participants. The questionnaire consisted of five sections: sources of information for medical professionals being utilized during their clinical decision making; their perception of EBM; their familiarity and use of electronic EBM sources; their knowledge of methodological terminology used in EBM; and their self-rated confidence in their EBM skills.
Investigators approached the study participants and explained to them the objectives of the study. A revisit was conducted on the date and time specified by the participants, during which the study questionnaire was administered after obtaining their written, informed consent. On average, the participants took approximately 20 minutes in filling out the questionnaire.
Statistical analysis
Data was entered and analyzed using Statistical Package for Social Sciences (SPSS) version 11.5. The results obtained were expressed in mean (standard deviation) and percentages.
Results
A total of 188 doctors were included in the study. The mean age of participants was 35+ 8.33 years. The majority (n=113, 60.1%) of participants were in the age group of 30–50 years. The baseline characteristics of the study participants are given in Table 1.
Baseline Characteristics of the Study Participants (N=188)
The majority of the participants referred to textbooks (n=182, 96.8%), followed by consulting their colleagues (n=176, 93.6%) or senior physicians (n=170, 90.5%) as the main sources of information for clinical decision making, as shown in Table 2.
Source of Information During Clinical Decision Making (N=188)
The attitude of practitioners regarding evidence based medicine is depicted in Table 3. The majority (n=180, 95.8%) of the participants were of the opinion that EBM should be taught in medical school. Around 90% of participants agreed that EBM helps in clinical decision-making. Despite the high rates of referring to colleagues for information, more than half (n=98, 52.1%) of the participants had used PubMed, followed by the Cochrane database (n=38, 20.2%) as shown in Table 4.
A MAJORITY OF STUDIES HAVE SHOWN THAT, THOUGH DOCTORS HAVE AN OPTIMISTIC ATTITUDE TOWARDS EBM, THERE IS LESS AWARENESS REGARDING ITS IMPLEMENTATION.
Perception of Medical Practitioners Regarding Evidence Based Medicine (EBM) (N=188)
Knowledge of Practitioners Regarding Resources Related to Evidence Based Medicine and its Usefulness (N=188)
The majority of participants had a good understanding of terms such as “sensitivity and specificity” (n=146, 77.6%) and “relative risk” (n=130, 69.1%). The majority (n=158, 84%) of participants were confident in conducting literature searches followed by ability in evaluating research (n=150,79.8%).
AWARENESS REGARDING THE RESOURCES RELATED TO EBM AMONG RESPONDENTS WAS HIGH, HOWEVER, ONLY A FEW OF THEM HAD APPLIED EBM IN CLINICAL DECISION MAKING.
Table 5 shows self-perceived barriers of practitioners regarding EBM. Lack of time (n=126, 67%) and insufficient skills (n=124, 66%) were considered the main barriers for practicing EBM.
Self-Perceived Barriers of Medical Practitioners Regarding Incorporating Evidence Based Medicine (EBM) (N=188)
Discussion
Doctors are the major agents of health care delivery, hence it is important for them to incorporate EBM in their routine practice. They should recognize the importance of EBM in delivering uniform quality treatment to all of their patients.2
The current study revealed that the majority of doctors referred to textbooks for clinical decision making, followed by the use of research articles, or consulting their colleagues and senior physicians. These observations were similar to those reported from Denmark13 and Canada.4,15 Dependence on others' intellectual ability leads to instinctive clinical decision making and standard textbooks reflect the approach of the author to a particular disease, which is not evidence based.13 Awareness regarding the resources related to EBM among respondents was high, however, only a few of them had applied EBM in clinical decision making. All the respondents were aware of PubMed and around half of them had used it. There might be an under-estimation of results related to utilization of databases because in a few instances respondents may have used a particular database but may not have been aware of the correct title. In comparison with studies conducted in Middle East Asian countries,8–10 the level of awareness in the present study was much higher regarding EBM. This might be attributed to increased exposure of doctors regarding EBM in the form of training and CME (Continuing Medical Education) at Kasturba Medical College (KMC), Mangalore and the teaching hospitals associated with it.
LACK OF ACCESSIBILITY TO JOURNALS AND DATABASES AT A WORKPLACE, AS WELL AS LACK OF TIME DURING BUSY CLINICAL SCHEDULES, HAVE BEEN THE MAIN OBSTACLES IN IMPLEMENTATION OF EBM.
Lack of accessibility to journals and databases at a workplace, as well as lack of time during busy clinical schedules, have been the main obstacles in implementation of EBM.16 These observations have further been strengthened by the findings of our study, as well as those conducted across different parts of the world.10–11 ,17–18
Introduction of EBM into the undergraduate medical curriculum enhances knowledge, attitude and skills among medical students, as reported by a study conducted in Mexico.19 A positive finding revealed by our study was that the majority of respondents welcomed the idea of incorporating EBM as part of the medical school curriculum. It was the belief of the majority of doctors that evidence based medicine will help in clinical decision making and in improving patient care. Similar views were expressed by participants in several other studies.8 ,10 ,17,18
Medical regulators can develop guidelines for training of students in medical schools regarding research methodology and bio-statistics. Regulators may also play a role in updating practicing physicians with the latest medical research, helping ensure that the best treatment is provided to the patients.
Only half of the participants in our study believed that EBM would reduce health care costs, which is in contrast to a study conducted in Iran,8 where higher proportions of the participants believed that health care costs could be reduced by practicing EBM. According to estimates by the National Health Accounts of India, 78.8% of health care spending by individuals in India is out-of-pocket expenditure.
Considerable knowledge of technical terms is essential for the interpretation of results in EBM. Half of the participants in our study had a significant knowledge of the technical terms used in evidence based medicine, such as “sensitivity and specificity” and “publication bias.” In conformity with this finding, understanding of publication bias was low in a study conducted among general practitioners in England.11 The findings of studies conducted in Saudi Arabia18 and Riyadh20 regarding knowledge of technical terms conforms with our findings. In contrast to our study findings, terms such as “odds ratio,” “meta-analysis,” and “likelihood ratio” were least understood in studies conducted in Saudi Arabia18 and Riyadh.20 Due to subjective assessment, there might be an overestimation of results regarding knowledge related to technical terms.
MEDICAL REGULATORS CAN DEVELOP GUIDELINES FOR TRAINING OF STUDENTS IN MEDICAL SCHOOLS REGARDING RESEARCH METHODOLOGY AND BIO-STATISTICS.
A higher proportion of participants in our study felt themselves proficient enough to use the skills related to EBM, which is in contrast to observations made in Australia.21
Medical regulations and policies should be based on the best current evidence, and for evidence to be effectively utilized by medical professionals these individuals need to be trained and appraised periodically. The evidence should be dynamic and also should be based on the socio-cultural context.
POSITIVE ATTITUDES AND HIGHER AWARENESS REGARDING EBM AMONG DOCTORS IN THE PRESENT STUDY, COMPARED TO OTHER REPORTED LITERATURE, IS AN ENCOURAGING FINDING.
Limitations
As the study was carried out in a teaching hospital linked with a medical college, results of the present study may not be generalized. Also, self-rated knowledge of respondents regarding EBM may differ from that of objective criteria, as demonstrated in a study conducted by Young et al in Australia.22
Conclusion
Positive attitudes and higher awareness regarding EBM among doctors in the present study, compared to other reported literature, is an encouraging finding. Medical regulators should utilize the best available evidence and experience in formulating policy on medical education and health care.
Acknowledgments
The authors are grateful to the participants who voluntarily took part in the study. We wish to acknowledge the support provided by the Department of Community Medicine, Kasturba Medical College, Mangalore and Manipal University for encouraging research and its publication in international journals.
Information from this study was originally presented at the 11th International Conference on Medical Regulation, hosted by the International Association of Medical Regulatory Authorities (IAMRA) in London Sept. 9–12, 2014.
About the Authors
↵All of the authors are affiliated with the Department of Community Medicine, Kasturba Medical College (Manipal University), in Mangalore, India:
↵Bhaskaran Unnikrishnan, MD, Associate Dean and Professor of Community Medicine
↵Darshan Bhagwan, MD, Assistant Professor
↵Akshay Sethi, MBBS, Medical Intern
↵Rekha Thapar, MD, Associate Professor
↵Prasanna Mithra, MD, Associate Professor
↵Nithin Kumar, MD, Associate Professor
↵Vaman Kulkarni, MD, Associate Professor
↵Ramesh Holla, MD, Assistant Professor
↵Avinash Kumar, MD, Assistant Professor
- Copyright 2015 Federation of State Medical Boards. All Rights Reserved.
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