As a GP, you are expected to understand the principles, strengths and limitations of evidence-based practice. The process of evidence-based practice was defined in the Sicily statement, 20031. It involves five steps:
- Translation of uncertainty into answerable questions
- Systematic retrieval of the best evidence available
- Critical appraisal for validity, clinical relevance and applicability
- Application of results in practice
- Evaluation of performance (at an individual or organisational level)
This topic overlaps with others and, in particular, should be considered in conjunction with the following RCGP Topic Guides:
- Consulting in General Practice
- Improving Quality, Safety and Prescribing
- Population Health
Transferrable research and academic skills
As a GP, you will need to acquire the research and academic skills that are necessary to keep up-to-date with progress in your field and to aid your decision-making. These skills may be applied in many areas of practice, including:
- the clinical management of patients, including treatment, referral, and acute care;
- dealing with uncertainty (through the use of best available evidence);
- challenging established practice and abandoning ineffective practices;
- prescribing;
- enabling safer working systems;
- improving the quality of health promotion and preventive medicine in your practice;
- audit and quality improvement within your practice or organisation;
- lifelong learning;
- improving population health, through engagement in activities ranging from local healthcare commissioning and public health policy to global climate change and sustainability; and
- primary care research, management, medical education or specialist roles.
A GP is expected to understand basic research methodology (for example, the difference between qualitative and quantitative data, and studies using social science methods as well as bioscience) and how different types of research activity may contribute to patient care. This includes:
- Qualitative and quantitative research:
- differences in forms of research and when each is appropriate;
- patient factors requiring both quantitative and qualitative analysis (for example, concordance with treatment); and
- techniques such as pilot studies, questionnaire design, field observations, interviews, focus groups and analysis of transcripts of narrative material; ethnography and observation, action research, case study; consensus methods such as Delphi or nominal groups
- Study designs and their advantages and disadvantages including:
- systematic reviews and meta-analysis;
- experimental: randomised controlled double blind;
- quasi-experimental: non-randomised control group; and
- observational: cohort (prospective, retrospective), case-control, cross-sectional.
- The most appropriate research design to examine a hypothesis:
- knowledge of the 'hierarchy of evidence' ranging from case reports, through case-control and cohort studies, to randomised controlled trials, systematic reviews and meta-analyses;
- strengths and limitations of research methodologies; and
- multi-morbidity research and its limitations
- Differences between research, clinical audit and quality improvement
Epidemiology concepts (see also Topic Guides on Population Health and Infectious Disease and Travel Health)
As a GP, you share responsibility for the health of your local population and should understand fundamental concepts in epidemiology. These include:
- The main reasons for patients consulting in UK primary care
- Population statistics including incidence, prevalence, mortality ratios, death rates
- Differences between population and individual risk
- Risk of disease in population groups, including your own practice population
- Qualitative measurements of health and approaches to qualitative research such as focus groups, Delphi analysis, ethnography
- Decisions or interventions made in the interests of a community or population of patients (for example, immunisation)
- Psychosocial, cultural, political, economic and other social determinants affecting evidence-based practice
- Inequalities in healthcare access and delivery.
Statistical concepts and terminology
As a GP, you are expected to know some basic statistical terminology, including the terms listed in the table below, and be able to conduct simple calculations for evidence-based practice.
|
|
- Absolute risk increase (ARI) or reduction (ARR)
|
|
|
- Negative predictive value (NPV)
|
|
|
|
- Number needed to harm (NNH)
|
|
- Number needed to treat (NNT)
|
|
|
|
- Positive predictive value (PPV)
|
|
|
|
|
|
|
|
- QALY (quality adjusted life year)
|
|
- Randomised controlled trial (RCT)
|
|
|
- DALY (disability adjusted life year)
|
|
- Data types (categorical, ordinal, continuous)
|
|
|
- Relative risk reduction (RRR)
|
- Distributions (normal and non-parametric)
|
|
|
|
|
|
|
|
|
|
- Inclusion/exclusion criteria
|
|
|
- Standardised mortality rates and ratios
|
|
|
|
|
|
|
|
|
|
- Validity (internal and external)
|
Critical appraisal
Your understanding of research design, epidemiology, and statistical concepts will help you to critically appraise written or graphical information such as trial results or abstracts, clinical governance data (audit, benchmarking, performance indicators) and data presented in medical journals. Further knowledge in this area includes:
- Clinical interpretation of results from common statistical tests, for example:
- analysis of variance, multiple regression, t-tests and non-parametric data (for example, chi squared, Mann-Whitney U); and
- simple (symmetrical, skewed) distributions, scatter diagrams, box plots, forest plots, funnel plots, statistical process control charts, Cates diagrams, decision aids
- Difference between causation and correlation
- Types of bias, reliability, validity, and generalisability
- Influence of individual bias and social factors on interpretation of research results
- Evaluation of guidelines to determine how suitable they are for clinical practice (including methodology, evidence-base, validity, applicability, authorship and sponsorship)
- Strengths and limitations of surveys and local healthcare reviews.
Evidence in practice
As a GP you should be aware of the skills needed to improve population, as well as individual, health. You should apply your understanding of evidence to your own practice and set your own learning objectives based on your clinical experience.
Further knowledge and skills in this area include:
- Applicability of population-level studies to individuals and certain groups (for example, groups commonly excluded from clinical trials, disadvantaged groups)
- Applicability of research results/conclusions to clinical practice
- Effective communication about evidence-based interventions to help patients make decisions about their health, including methods of calculating, demonstrating and explaining risk to patients
- How to search for and retrieve valid information (including using online and other resources to help your own learning)
- Influence of health economics studies on healthcare resource allocation and guidelines
- Pharmaceutical marketing
- Potential tensions between evidence-based practice and patient values/choices
- Predictive personalised care (for example, drug treatment)
- Reasons for lack of evidence about certain interventions (for example, rare conditions, conditions that have low morbidity or low pharmacological input)
- Recognising that poverty is a common cause of ill health and consider this when interpreting research. For example, a health outcome attributed to a certain characteristic (for example, ethnicity) may be due to an underlying environment of disadvantage
- Role of large GP records databases (for example, QResearch, the Clinical Practice Research Datalink etc.) and how to contribute patient data to these
- Use of decision aids and information technology in clinical and professional practice.
Screening (see also RCGP Topic Guide on Population Health)
- Information available to patients to aid decision making with regard to screening
- Population-based prevention strategies including immunisation, health screening and population screening
- Principles of screening (for example, Wilson’s criteria) and the concepts of primary, secondary and tertiary prevention; their application to screening programmes and recall systems
- Risks and benefits of screening programmes.
Sharing knowledge
As a GP you have a role in sharing knowledge with others. This may include formal or informal teaching, mentoring, supervising colleagues and peers, and education in the wider community. Underpinning this is the need for better patient care. Important principles include:
- Understanding that teaching other people involves more than imparting information
- The difference between clinical and educational supervision and the different competences required in the two roles
- Being prepared, as a doctor, to act as an educator and learner within your local community
- Approaches to effectively teach and mentor others within a team
- How to engage those you are teaching in a dialogue about their values and goals
- Techniques to adjust your own teaching style to suit the individual as well the subject, being aware that not every individual will learn in the same way
- How to give and receive effective feedback from individuals or groups, following the principles described in the General Medical Council's Good Medical Practice
- Understanding of information governance, intellectual property, legal, privacy and security issues when sharing knowledge (including via online and social media channels), particularly when this involves other people’s work or identifiable information about individuals.
Ethics and governance in education and research
As a GP you are likely to participate directly or indirectly in research and educational activity which may have ethical and clinical governance implications. For example, you may be an educational supervisor or academic GP, your practice may be part of a research network, or you may be asked to assist in recruiting patients to clinical trials. Also, you may see patients who are involved in clinical trials or be asked for your professional or expert opinion on a piece of research. It is important, therefore, to understand the ethical and governance principles that underpin such activities, and have an awareness of your own attitudes, values, professional capabilities and ethics in this context.
While promoting the benefits, you should assure patients that participation in research and education is voluntary and that declining to participate will not negatively impact on their care.
Important areas of knowledge in this area include:
- Autonomy and patient choice
- Confidentiality and information governance (including relevant legislation)
- Conflicts of interest (for example, incentives for certain interventions)
- Consent
- Ethical approval and role of ethics committees
- Impact on patients and staff of GP research
- Patient safety
- Research fraud