Evidence based practice

This Topic Guide explores part of the RCGP curriculum, Being a General Practitioner. It will help you understand important issues relating to evidence-based practice, research and sharing knowledge by describing the key learning points. It also contains tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources.

Summary

  • Evidence-based healthcare involves using scientific rigour to appraise evidence from a wide range of sources to best benefit the patient or the service. Primary care research can enhance understanding about the causation, prevention and treatment of disease, which can in turn guide effective and relevant health policies and practice.
  • As a GP, you should be able to understand and communicate the results of relevant population-level research, and to decide whether the findings are applicable to your own patients. In particular, you should be able to effectively communicate risk 
  • Whilst being able to adopt a non-judgmental, evidence-based approach, it is essential to adopt a collaborative approach to care. This requires taking into account the patient’s values, priorities and circumstances, the community, and the healthcare setting 
  • Be aware of individual bias (including unconscious bias) in interpreting data, and follow the GMC's Good Medical Practice guidance in respecting culture, disability, religion, gender, sexuality, social and economic status 
  • As learners and teachers, every GP should be equipped to share knowledge with others through, for example, teaching, mentoring and supervision. 

Knowledge and skills guide

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: 

  1. Translation of uncertainty into answerable questions 
  2. Systematic retrieval of the best evidence available 
  3. Critical appraisal for validity, clinical relevance and applicability 
  4. Application of results in practice 
  5. 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 (AR)   
  • Meta-analysis                     
  • Absolute risk increase (ARI) or reduction (ARR)
  •  Mode 
  • Association
  •  Negative predictive value (NPV) 
  • Bayesian probability 
  •  Null hypothesis 
  • Bias 
  •  Number needed to harm (NNH) 
  • Blinding 
  •  Number needed to treat (NNT)  
  • Case control 
  •  Odds & Odds Ratio 
  • Case fatality 
  •  Positive predictive value (PPV)  
  • Cohort
  •  Prevalence 
  • Confidence intervals 
  •  Probability 
  • Confounding 
  •  p-values  
  • Correlation
  •  QALY (quality adjusted life year) 
  • Crossover
  •  Randomised controlled trial (RCT) 
  • Cross-sectional 
  •  Range 
  • DALY (disability adjusted life year) 
  •  Regression to the mean 
  • Data types (categorical, ordinal, continuous) 
  •  Relative risk (RR) 
  • Discrimination 
  •  Relative risk reduction (RRR) 
  • Distributions (normal and non-parametric) 
  •  Reliability 
  • Event rate
  •  Risk ratio 
  • Generalisability 
  •  Sampling 
  • Hazard Ratio 
  •  Sensitivity 
  • Incidence 
  •  Specificity 
  • Inclusion/exclusion criteria 
  •  Standard deviation (SD) 
  • Likelihood ratios 
  •  Standardised mortality rates and ratios 
  • Mean 
  •  Systematic review 
  • Median  
  •  Trends  
 
  •  Triangulation 
 
  •  Type 1 and 2 errors 
 
  •  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

How to learn this area of practice

Portfolio-based learning (for example, the RCGP e-Portfolio) is a useful approach to manage your professional education, serving as a continually updated repository to enable your knowledge, reflections and learning to be recorded and reviewed. Learning entries may arise from a wide range of activities. These include:

  • Compliments and complaints 
  • Critical and significant event analyses 
  • Discussions with peers, mentors and teams 
  • Feedback from teaching sessions 
  • Guidelines (for example, NICE, SIGN) 
  • Learning events – such as attendance at lectures, courses and workshops 
  • Online learning and e-Learning activities 
  • Patient feedback surveys and engagement meetings 
  • Practice-based learning events or learning with a group of peers 
  • Quality Improvement Projects (including audits) 
  • Reading journals and electronic materials 
  • Reflection on a patient’s unmet needs (PUNs) or the doctor’s educational needs (DENs) 
  • Structured feedback from supervisors, colleagues and teams

To become an effective and efficient professional learner, it is important to develop the habit of embedding your learning and continuing professional development (CPD) into your daily practice (in all your roles), adapting your approaches to your personal development aims and the context in which you work. 

Discussions with supervisors, appraisers and mentors will enable you to recognise not only your preferred learning style but also the best learning opportunities for specific needs. For instance, new NHS guidelines can be learnt through reading documents or attendance at a lecture, but the development of a new system of care within a practice may best be achieved by learning and working with your practice team. 

A good understanding of how you and your colleagues learn will not only help you in your own CPD but also enable you to help develop the whole team through group learning activities. 

Work-based learning

Learning from contact with patients (including direct observation of clinical contact) is a prerequisite for good practice. It may not always be easy, however, for you to apply evidence in daily clinical practice – for example, when working with a patient who has views or values that diverge from your own. However, patients and carers will often place their trust in your advice, which is why it is important that you build a sound evidence-base to inform your decisions, gained from understanding research papers, reviews and clinical guidelines.  

Many learners find it more engaging to practice critical appraisal skills within a team context (for example, appraising and debating a guideline or research paper within a journal club). Similarly, many of your best learning opportunities may come from team discussions relating to significant event audits, audits performed in the practice or from audit data collected around the locality and used as a benchmarking tool to compare practice performance.  

Additionally, working with research networks allows you to get a sense of research governance and the principles of good research practice.   

Self-directed learning

Self-directed learning, reading books, journals, abstracts, reviews, and editorials, amongst other sources, will give you an excellent opportunity to engage in topics you choose yourself, guided by your own educational needs. e-Learning modules, such as the RCGP Essential Knowledge Updates, provide opportunities to learn new clinical information. Local audit group meetings may provide opportunities to learn about audit. You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare

Multi-disciplinary learning

You can obtain useful knowledge and skills from a wide range of different professionals. This could be through direct clinical contact with other professionals providing services to your patients – for example, in clinics with midwives, practice nurses, and health visitors. Opportunities also exist through carefully reading correspondence from other professionals. Other sources include in-house or locality-based educational programmes. Multi-disciplinary team working offers the opportunity for many different staff to work together and understand each other’s perspectives.  

Structured learning

There are many opportunities for more formal (structured) learning, such as courses on evidence-based practice. These include research and clinical update study days, which could be offered through RCGP or other hosts, such as university departments. Your local training programme will offer updates and workshops tailored for trainees.  

Academic work in general practice

Many GPs develop academic careers, in addition to their clinical work. This can be done through specific academic training posts, developed jointly by postgraduate/workforce deaneries and universities, or through becoming tutors in undergraduate medicine and developing academic research skills related to that. There are pathways for entering academic practice after getting your Certificate of Completion of Training (CCT), and you can get more information on this through the RCGP.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Interpretation of prescribing data audit and prioritising changes 
  • Calculating and explaining common terms used in risk communication such as ARR, RRR, NNT and NNH 
  • Interpretation of graphical and tabular data 

Clinical Skills Assessment (CSA)

  • Discussion with a patient who is unsure about whether they should start on a statin, after they have been identified to have a 10-year cardiovascular risk of 15%  
  • Phone call: a father wants to know why an antibiotic was not prescribed during an earlier consultation for his child, whom now has acute otitis media 
  • An elderly woman with well-controlled hypertension has been identified by a practice audit as having atrial fibrillation – but she is not taking anticoagulation therapy. 

Workplace Based Assessment (WPBA)

  • Log entry reflecting on the visit of a pharmaceutical company representative promoting a specific drug 
  • Audit of your antibiotic prescribing against current national guidance and evidence  
  • Consultation Observation Tool (COT) discussion about the risks and benefits of Hormone Replacement Therapy (HRT) for a perimenopausal woman.

Next: Improving quality safety and prescribing >

References

1 Dawes M, Summerskill W, Glaziou P et al. Sicily Statement on evidence-based practice BMC Medical Education 2005: 5; 1 

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