Career stage and work setting create different barriers for evidence-based medicine Maartje H.J. Swennen MD MSc, 1 Geert J.M.G. van der Heijden PhD, 2 Geert H. Blijham MD PhD 3 and Cor J. Kalkman MD MSc PhD 4 1 PhD Fellow, Department of Clinical Epidemiology, Division Julius Centre for Health Sciences and Primary Care, Staff Member, Directorate of Executive Board, 2 Associate Professor, Coordinator of the Epidemiology and Evidence Based Medicine Education Program, Department of Clinical Epidemiology, Division Julius Centre for Health Sciences and Primary Care, 3 Former Chairman and Vice-Dean of Executive Board, and Professor Emeritus of Internal Medicine, 4 Research and Education Manager, Professor of Anesthesia, Division Perioperative and Emergency Care, and Director of Patient Safety Centre, Directorate of Executive Board, University Medical Centre Utrecht, Utrecht, The Netherlands Keywords barrier, EBM, EBP, implementation, system 1 and 2 processing, triage Correspondence Maartje H.J. Swennen University Medical Centre Utrecht Stratenum 6.131 Heidelberglaan 100 PO Box 85500 3508 GA Utrecht The Netherlands E-mail: m.h.j.swennen@umcutrecht.nl Accepted for publication: 3 February 2010 doi:10.1111/j.1365-2753.2010.01435.x 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 inter- views. 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. Introduction Practising evidence-based medicine (EBM) involves making deci- sions about the care of individual patients by integrating the current best research evidence in a conscientious, explicit and judicious manner with clinicians’ expertise and patients’ values [1,2]. Increasing use of EBM should result in more appropriate health care for both individuals and populations. Despite more than 20 years of worldwide efforts to progress EBM, the gap between available and applied evidence remains substantial [3–11]. As a consequence, appropriateness of care can be ques- tioned [12,13], and the benefits of health care are likely to be suboptimal. While EBM is not necessarily about lower costs, indi- vidual and societal costs are arguably higher than would otherwise be the case if high-quality evidence was routinely incorporated into routine care [14]. Journal of Evaluation in Clinical Practice ISSN 1365-2753 © 2010 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 17 (2011) 775–785 775