Evidence seems to change frequently

EDITOR—Freeman and Sweeney's study on why general practitioners do not implement evidence seems to share the underlying assumption of so much that is written on this subject—that evidence is clear cut, and the only problem is getting practitioners to put it into practice.1 My perception of evidence, however, is that it is often slippery—at best frequently changing and at worst contradictory and confusing—and that best evidence is often not very good. Part of the problem is therefore deciding exactly what to put into practice.

The findings and interpretation of individual papers, systematic reviews, meta-analyses, and reviews of systematic reviews and meta-analyses are regularly debated in the BMJ. Anticoagulation was one of the clinical areas discussed by the participants in Freeman and Sweeney's study, but stroke prevention in atrial fibrillation is controversial. How many general practitioners who have read the papers on atrial fibrillation in the BMJ over the past couple of years feel confident about the conclusions to be drawn from this evidence as to which of their patients would be best treated with warfarin and which with aspirin? Clinical Evidence helps,2 but can we be sure that its authors are more objective than the combatants in the BMJ?

The fickleness of evidence is inconvenient but would be easier to live with if it was more widely acknowledged in discussions of implementation.

Learning environments must be created that capitalise on teams' wealth of knowledge

EDITOR—Freeman and Sweeney's paper on why general practitioners do not implement evidence highlights the importance of good knowledge management for primary care and the weakness of relying solely on the dissemination of evidence based medicine.1 Evidence based medicine is an explicit and highly formalised form of knowledge made available though journals, websites, and lectures. Added authority is given when it is made part of national targets or incentive schemes.

By way of contrast the commercial knowledge management literature, while acknowledging the need for explicit knowledge, places enormous value on tacit knowledge.2 Tacit knowledge includes intuition and problem solving ability that is gained through experience and interaction with people. Externalisation of this tacit knowledge, so that organisations and individuals can learn from it, is seen as critical to commercial success. Forums for learner centred approaches to knowledge management, where this tacit knowledge is shared, are small groups, workshops, and one to one learning situations.

Freeman and Sweeney's paper shows how, through evidence based medicine, primary care is provided with a language to describe formalised explicit knowledge. What seems to be lacking is a language for valuing and externalising the tacit knowledge possessed by primary care professionals.3 The paper lends support to the argument that primary care organisations need to have knowledge management strategies that aren't simply about delivering explicit formalised knowledge. This is not to decry evidence based medicine but to argue that other knowledge management strategies are needed as well.

It is all too easy for front line medical services such as general practice to be seen as routine patient management problems4 that can be solved by the dissemination of evidence based medicine and information centred knowledge. The assumption is that all general practice needs is access to the right decision support; evidence based medicine will then be implemented.

Wyatt says that strategies to use tacit knowledge should not occur “at the expense of distracting clinicians, policy makers and funders from the key task of making agreed explicit knowledge readily available in suitable forms.”4 Freeman and Sweeney's paper provides a refreshing challenge to this by highlighting the social complexity of implementing evidence based medicine. The knowledge management literature suggests that a learner centred approach, exploiting tacit knowledge, can address some of these issues.

Freeman and Sweeney show that simply disseminating existing evidence will not lead to its implementation. Primary care organisations need to create learning environments that capitalise on the wealth of knowledge held within teams. Only with such a foundation will the dissemination of evidence based medicine be worth while.