The European Journal of Public Health Advance Access originally published online on July 28, 2005
The European Journal of Public Health 2005 15(5):480-483; doi:10.1093/eurpub/cki020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Health Services Research |
Medical practitioners in outpatient care: who is interested in participating in EBM courses?
Results of a representative postal survey in Germany
Thorsten Meyer, Angelika Stroebel and Heiner Raspe** Medical University Schleswig-Holstein, Institute of Social Medicine, Campus Luebeck, Luebeck, Germany
Correspondence: Dr T. Meyer, Institute of Social Medicine, Medical University Schleswig-Holstein, Campus Luebeck, Beckergrube 43–47, D-23552 Luebeck, Germany, tel: +49 451 7992526, fax: +49 451 7992522, e-mail: thorsten.meyer{at}sozmed.uni-luebeck.de
Received January 20, 2004, accepted May 11, 2004
 |
Abstract |
|---|
 Top Abstract MethodsResultsDiscussionReferences |
|---|
We surveyed the attitudes of medical practitioners towards evidence-based medicine (EBM) and characterized those with an interest in participating in EBM courses. A random sample of 900 outpatient care doctors stratified by level and field of specialization was surveyed by means of a postal questionnaire. Importance of knowledge on information management, a positive attitude towards EBM and not yet doing critical appraisal were significant predictors of interest in participating in EBM courses. Low participation rates of outpatient care doctors in EBM courses are not due to attitudinal or general motivational problems. Although possible predictors of interest in participation could be specified, further factors contributing to actual participation need to be identified.
Keywords: continuous medical education, evidence-based medicine, outpatient care, postal survey, primary care
In contrast to other European countries, such as Great Britain, Finland or The Netherlands, Germany's health care did not take note of evidence-based medicine (EBM) until the mid-1990s.1 In Germany, its protagonists are found in University settings, health care administrations and social law. Since EBM is only gradually becoming integrated into medical education, medical practitioners interested in EBM have to enrol in EBM courses offered in the context of continual medical education. However, in our annual EBM training courses held since 1996, we have found low participation rates of primary care physicians (
5–10% of all participants). Even courses especially tailored to these physicians and extensively advertised to all regional doctors in private practice have suffered from low attendance rates. We must assume that EBM has not yet reached medical practitioners in outpatient care, and the reason for this is unclear. Results of two surveys from Australia2 and Great Britain,3 as well as a qualitative study from Canada,4 have shown a rather positive attitude towards EBM among general practitioners. At present there are no such data from Germany. We aimed to assess the attitudes of medical practitioners towards EBM and to characterize those with an interest in EBM courses.
|
Methods |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
In 2002 we conducted a postal survey of a random sample of 900 general practitioners and medical specialists working in private practice (22% of the total) in the northern German state of Schleswig-Holstein (2.8 million inhabitants). Since outpatient treatment is offered both by general practitioners and medical specialists, the sample was stratified by level and field of specialization (300 per stratum): (i) general practitioners; (ii) surgically trained specialists (e.g. surgeons, gynaecologists); and (iii) non-surgical specialists (e.g. internists, neurologists). Two reminders were sent to non-responders. The questionnaire consisted of 56 questions, most of them with closed response formats. They covered awareness of EBM, attitude towards EBM, EBM techniques used in daily routines, organizational preferences, sociodemographic characteristics, and interest in participating in EBM courses.5 The latter was assessed by a 5-point scale dichotomized to distinguish those interested (scores 4 and 5) and those indecisive or not interested (scores 1–3). Those not familiar with the term EBM were asked to skip questions on attitudes towards EBM and use of EBM techniques. The questionnaire was accompanied by an introductory letter explaining the meaning of the study and by a leaflet with information on EBM and an offer to participate in an EBM course. A qualitative pre-test was conducted in order to improve comprehensibility and feasibility of the questionnaire. Mean duration of completion was found to be 20 min. The only information available for a non-response analysis were age, gender and level/field of specialization. The association between characteristics or responses of the medical practitioners and interest in participating in an EBM course was analysed by crude odds ratios in the univariate analyses, and adjusted odds ratios estimated by a logistic regression model in a multivariate analysis. To allow direct comparison between the univariate and multivariate analyses, both were based on responders with complete data. Statistical analyses were conducted using SPSS software (version 11.0.1).
|
Results |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
The overall response rate was 65.6% (590/900). Non-response was not associated with level and field of specialization: (i) 62.7% versus (ii) 70.0% versus (iii) 64.0% (
2 = 4.055, df = 2, P = 0.132). Elderly female physicians were slightly underrepresented (females: responders' age 48.0 years versus non-responders' 51.0; males: responder age 52.5 years versus non-responder 52.5; Fresponsexsex = 5.821, df = 1, P = 0.016). In all, 2.4% (14/590) of the responders were excluded from further analysis because of unreliable data (>25% missing data), leaving 576 questionnaires for analysis. Sociodemographic characteristics and descriptive study results are given in table 1. Table 2 contains the results of the association between characteristics or responses of the respondents and their interest in participating in an EBM course.
|
|
In univariate analyses, age was found to be slightly associated with interest in participating in an EBM course. Doctors >55 years of age appeared to be less interested. Self-rated familiarity with the internet and English language proficiency were not found to be associated with interest in participation. Strong positive relationships were found with items that cover the appraisal of EBM. In addition, those respondents who reported to have used guidelines or systematic reviews in their work already and those who value the importance of knowledge on information management had a higher probability of being interested in participation in an EBM course.
A multivariate logistic regression with interest in participating in an EBM course as a dependent variable yielded a positive attitude towards EBM both in general and in daily work, leaving knowledge on information management as important and reporting not doing critical appraisal in daily work as the only remaining significant predictors.
|
Discussion |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
Altogether we found a substantial positive attitude towards EBM among medical practitioners, which parallels the findings from surveys from Australia2 and the UK.3 A positive attitude towards EBM and appreciation of information management are the primary possible determinants of an interest in participating in EBM training. Results indicated that medical practitioners who are older than 55 years might be less interested. This result might not be directly related to EBM itself, but rather an expression of a general decrease of interest in group continuous medical education activities in older physicians.6
The sample for the study was drawn from the population of medical practitioners in Schleswig-Holstein (Germany). However, because of a comparable medical education and training across Germany, the results of our study may well be generalizable to other German regions, with a possible exception of the New Laender of the former German Democratic Republic. A possible limitation of this study is a potential bias favouring a positive attitude towards EBM, because non-responders (about one-third of the original sample) might be expected to be rather indifferent or even sceptical towards EBM, implying selection bias. In addition, we cannot rule out social desirability bias. Taking into account the limitations of the questionnaire approach, we need to learn more about the doctors' personal understandings of EBM. It is possible that a number of respondents might appraise their medical decisions to be based on evidence, although their knowledge of the philosophy and techniques of EBM might be limited. In this vein, doctors might feel they already do critical appraisal of published studies, without ever having dealt with the strategies of critical appraisal in the tradition of EBM. This might explain the appearance of the use of critical appraisal as a negative predictor of interest in participation in EBM courses. Taking into account a possible tendency to overestimate personal skills in EBM,7 we hesitate to interpret this finding as an indication of sufficient knowledge in EBM with no further training needed.
Important general prerequisites of actual participation in EBM training courses—positive attitudes towards EBM and substantial numbers of practitioners with interest in EBM courses—were found in the present sample. However, we have not yet identified those factors responsible for the extremely low participation rates of medical practitioners in outpatient care in EBM training courses, even in those offered by the regional general medical council. General practitioners and medical specialists should not have differed in their awareness of the courses, because these had twice been made public in the official announcements of the regional medical council. In order to foster EBM in medical practitioners who care for the vast majority of patients in the community, more specific variables need to be identified to account for actual low participation rates. More active ways of reaching out for possible multipliers have to be developed, e.g. by targeting members of local quality circles and implementing a tutorial system with continuous support for local clinicians.
Key points
|
|
Acknowledgments |
|---|
This analysis is part of the project ‘cooperative development, implementation and evaluation of a curriculum for medical education in evidence-based medicine/clinical epidemiology’, supported by the Stemmler foundation (Az: T 206–10.771).
|
References |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
1 Raspe H. Grundlagen und Theorie der evidenzbasierten Medizin (EbM) [Basis and theory of evidence-based medicine (EBM)]. In: Kunz R, Ollenschläger G, Raspe H et al, editors. Lehrbuch evidenzbasierte medizin in klinik und praxis. Köln: Deutscher Ärzte-Verlag, 2000: 38–49.
2 Gupta L, Ward JE, Hayward RSA. Clinical practice guidelines in general practice: a national survey of recall, attitudes and impact. Med J Aust 1997;166:69–72.[Web of Science][Medline]
3 McColl A, Smith H, White P, Field J. General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998;316:361–5.
4 Putnam W, Twohig PL, Burge FI et al. A qualitative study of evidence in primary care: what the practitioners are saying. CMAJ 2002;166:1525–30.
5 Meyer T, Ströbel A, Raspe H. Evidenz-basierte Medizin aus Sicht niedergelassener Ärztinnen und Ärzte: ein repräsentativer Survey zu Akzeptanz und Fortbildungsinteressen [Evidence-based medicine from the perspective of primary care practitioners: a representative survey of acceptance and interests in education]. Z Arztl Fortbildung und Qualitätssicherung 2004;98:293–300.
6 Goulet F, Gagnon RJ, Desrosiers G et al. Participation in CME activities. Can Fam Physician 1998;44:541–8.[Web of Science][Medline]
7 Young MJ, Glasziou P, Ward JE. General practitioners' self ratings of skills in evidence based medicine: validation study. BMJ 2002;324:950–1.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||