Table 3

Barriers to the use of evidence-based medicine (EBM) by GPs

Evidence	GP's preferences	Patient's situation	Practice setting
• Translating trials into practice13,18,30	• Knowledge of EBM15,26	• Treatment expectations different from evidence25,31,33	• Applicability of evidence to general practice13,14,17,18,22,24,27,30,34

• Use of evidence is complicated23	• Difficulty keeping up13,27	• Adapting to preferences, beliefs, and demands different from evidence15,24,26,30,33	• Lack of time:13–16,20,21,25,28–31,33
			• to search for evidence17,19,33
			• to access evidence19,26
			• to appraise evidence33
			• to apply evidence23
			• to keep up to date15–17
			• to discuss with patient33
			• per patient33
			• to reflect on practice26

• Change of existing evidence15,19	• Difficult to find information14,17,27	• Reluctant to comply with treatment34	• Lack of managerial support20,22,27

• User-friendliness: need for summaries,14 also for better formats22,30	• EBM skills14,15,19,24,30,31,33	• GP's desire for patient's appreciation17	• Lack of investment/incentives27,31

• Lack of (qualitatively good) available evidence15,24,26,30,31,33	• Attitude towards EBM15	• Discussing with patient24	• Fear of punishment or litigation:18,25
	• limited in treatment options and clinical freedom15,18,23,25	• ‘convincing and pressure to meet	• EBM is a threat24,31
		• expectations’17,26
	• lack of interest/motivation32	• ‘selling evidence to patients’17
	• ‘EBM not helpful’16
	• ‘EBM will not benefit practice’27
	• in older people (less effort applying)13
	• lack of ownership/commitment13

• Contradictions in evidence15,17,18,26,27,30	• Lack of training20,25,32	• Not accepting uncertainty of evidence18	• Money needed:15,16,27,30,33
	• direction in training13,15,27		• for access to internet and resources26
			• EBM carries no financial gain27,31

• Too much available evidence24,31	• Personal and professional experiences different from evidence34	• Confidence in GP reduced by guidelines25	• Rural location26

• Lack of resources14,15,26	• Fear of side effects17 or harm19	• Relationship between GP and patient34	• Morale24

• Available sources not helpful16	• Harmonising guidance19,30	• Experiences of the patient different from evidence34

• Access (computers, internet, journals, databases, or libraries)14,16,21,23–31	• Practicalities of real life13,24	• Toleration of uncertainties18

• Lack of trust in origin17,18 and in independence of evidence sources15 or information spread by other organisations (not evidence based)15	• Lack of confidence19,30	• Clinical symptoms, disease14

• Level of evidence22	• Familiarity with new role15,26	• Psychosocial context18,31

• Implications of the evidence22	• Personal and organisational inertia24	• Influence of media15,24

• The language in which evidence is written20	• Culture29	• Information retrieval by patient20

• Lack of help in interpretation by experts/specialists13,14,20	• Influence of belief of peers19,24–26,31	• Words of GP and presentation of information used by GP34