Barriers to the Evidence-based Patient Choice (EBPC) vs EBM. Paper Study. Evidence based medicine interest

7/30/2019 Barriers to the Evidence-based Patient Choice (EBPC) vs EBM. Paper Study. Evidence based medicine interest.

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Barriers to the evidence-based patient choice (EBPC) consultation

Sarah Ford*, Theo Schofield, Tony HopeThe Ethox Centre, University of Oxford, Institute of Health Sciences, Old Road, Headington, Oxford, OX3 7LF, UK

Received 4 May 2001; received in revised form 20 July 2001; accepted 24 September 2001

Abstract

This study was conducted to explore barriers to the implementation of the evidence-based patient choice (EBPC) consultation in

medical practice. The theory behind EBPC encompasses the idea that patients should be provided with evidence-based information in a way

that facilitates their ability to make choices or decisions about their health care. Semi-structured interviews were conducted withpurposively selected general practitioners (GPs) (n 11), hospital doctors (n 10), practice nurses (n 5), academics (n 11) and lay

people (n 8). Qualitative analyses of participants responses were conducted to identify key themes and categories. Lack of medical

evidence per se and evidence relevant to individual patients were the most commonly reported barriers to the EBPC consultation. Other

barriers included: doctors attitudes, limited time for doctors to keep up with the evidence and to introduce evidence into the consultation;

economic and resource constraints and a lack of technical resources and training to enable doctors to practice this type of approach.

# 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Evidence-based patient choice; Evidence-based medicine; Patient-centred care; Patient partnership; Medical consultation

1. Introduction

The theory of evidence-based patient choice (EBPC)brings together two important modern movements in wes-

tern health care namely evidence-based medicine (EBM),

and patient-centred care [1]. Traditionally, EBM and patient-

centred medicinehave belonged to separate worlds. However,

bridging the gap between these two paradigms has been

described as a major challenge for all who want to protect

the humane face of medicine in the next millennium [2]. The

call for the integration of EBM and patient-centred care is

partly a response to the fact that medical practice is increas-

ingly being dominated by scientific evidence that potentially

bypasses patients own preferences and values. In the

medical consultation, EBPC means providing patients with

evidence-based information in a way that facilitates their

ability to make choices or decisions about their health care.

By combining EBM with patient-centred care, information

that is of value and personal importance to patients is

considered in parallel with scientific evidence-based infor-

mation as part of the decision-making process.

EBPC is one of several models in existence which advo-

cates providing patients with the necessary information to

enable them to become involved in decisions about their care

[37]. The move towards increasing patient involvement

is driven by a theoretical concern for respect for patient

autonomy [8]. This emphasises that patients should be in aposition to choose whether to accept an intervention or not

as part of their general right to determine their own lives.

Specifically, EBPC recognises the fact that individuals differ

both in what they value and in their propensity to take risks

[1].

The concept of shared decision-making between doctors

and patients is an area of considerable debate, both in terms

of the principles and competencies involved. The traditional

paternalistic model of medical decision-making has largely

become seen as anachronistic. However, there is still rela-

tively little known about the desire of patients to have a role

in medical decision-making. Empirical evidence (reviewed

by Stewart) [9] suggests that giving patients information and

involving them in decisions about their health care can result

in beneficial psychological, physical and physiological out-

comes, but there is a dearth of studies on the varying needs

of different patient groups [10]. Along side this, there is a

growing consensus that sharing medical decisions is justifia-

ble on humanistic grounds alone [11].

Currently, opinions differ on the competencies required

and the conditions necessary for shared decision-making

to occur. For example, the exploration of patient preferen-

ces for information and involvement in decision-making

are common preliminary stages in some models [4,7].

Patient Education and Counseling 47 (2002) 179185

* Corresponding author. Tel.: 44-1865-227049.

E-mail address: [email protected] (S. Ford).

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However, some commentators [6] posit that it is illogical to

ask about a patients preferred role in decision-making until

they have information concerning the possible harms and

benefits of the choices they face. Only when armed with this

information will patients be in a position to decide what is

best for them. Gwyn and Elwyn also suggest that not all

medical encounters lend themselves to a shared approach. Forexample, decisions concerning the use of antibiotics to treat

viraldisorders aremore likelyto be informeddecisions, in line

with the doctors preference. Therefore, a situation of equi-

poise where several effective options exist must be present in

order for a shared decision to successfully take place [12].

Barriers to shared decision-making and EBM have pre-

viously been investigated in empirical studies. Reasons why

general practitioners (GPs) do not engage in shared decision-

making include: lack of time; other organisational pressures;

the belief that patients lack the will or ability to participate in

shared decision-making [13]; and lack of skills needed by

doctors to involve patients in clinical decision-making [6].

EBM is commonly criticised for being doctor-centred, in that

it focuses on the doctors interpretation of evidence and

diminishes the importance of human relationships and the

role of the patient in the consultation [14]. However, it can be

argued that the term evidence-based is becoming outdated

as consensus grows that EBM should acknowledge multiple

dimensions of evidence including practical evidence based

on individuals interpretation of experience [15]. There is a

demand for a new definition of EBM that includes evidence

produced outside science [16].

This qualitative study explores informed opinion con-

cerning the perceived obstacles to achieving a successful

EBPC consultation. We stress that we were testing reactionsto the concept rather than to the actual existence of the EBPC

consultation. As part of a larger study to investigate the

elements and skills required for a successful EBPC con-

sultation, a series of semi-structured interviews were carried

out with key informants. We deliberately selected a range of

knowledgeable and highly motivated participants, many of

whom we considered to be well informed about the debates

concerning EBM and patient-centred care. This was to

acquire informed opinion on the feasibility of EBPC work-

ing in practice.

2. Participants and methods

Purposive sampling was used to recruit participants who

were anticipated to have an interest in issues relating to

shared decision-making, EBM and patient-centred care. We

wanted to tap into the opinions of professionals with an

understanding of these concepts. Those invited to take part

included 12 GPs, 12 hospital doctors, 12 academics, 10 lay

persons and 10 nurse practitioners. GPs and hospital doctors

were chosen from a list of medical student tutors all of whom

were known to the authors. Academics were chosen on the

basis of their published contributions to the debate on patient

involvement in health care (four were also part-time GPs).

Lay people who had keen interests in issues connected with

patient empowerment were recruited through the Oxford-

shire Community Health Council. Participating GPs recom-

mended nurse practitioners who they considered being au

fait with the topic of investigation.

All potential participants received an invitation letterwhich included information about the concept of EBPC.

Those willing to take part received a pre-interview prompt

sheet one week before being interviewed. This was to

enable them to familiarise themselves with the concept of

EBPC. The interviews took place at respondents place of

work except for the lay people, most of whom were inter-

viewed in their own homes. At the start of each interview the

researcher explored respondents personal understanding of

the concept of EBPC. Interviewees were then asked for their

own opinions on the essential elements and skills needed for

a successful EBPC medical consultation to occur in practice

and for their own views on existing barriers to implementing

EBPC. The results from the former question will be pub-

lished elsewhere. Each interview was audio-taped and lasted

between 30 and 45 min.

The interviews were analysed using the constant compar-

ison method, a qualitative technique which involves the

systematic sifting and comparison of items of data to reveal

and establish the mutual relationships and internal structure

of categories [17]. Responses were transcribed and divided

into simpler text units that were entered into a database for

ease of coding. Units of text referring to similar issues were

separated from dissimilar units and systematically grouped

together by one coder. Each grouping represented a provi-

sional theme. When all the text units had been coded intocategories under each theme by the first coder, the category

codes were re-applied by a second independent coder.

The initial level of agreement between coders was 90%.

Discussions between the two coders concerning coding

categories resulted in reorganisation of some of the pre-

liminary categories before total agreement was reached and

the final codes were agreed.

3. Results

Those who agreed to participate included 11 GPs, (n 3

women), 10 hospital consultants (n 4 women), 11 aca-

demics (n 7 women), eight lay persons (n 1 male) and

five nurse practitioners, all of whom were women. In total,

45 respondents were entered into the analysis, 26 being

women. Six main themes emerged from the data and these

are presented in Table 1.

3.1. Limitations of the evidence

3.1.1. Lack of evidence

There was a general concern about the lack of evidence in

some areas of medicine and a belief that some medical

180 S. Ford et al. / Patient Education and Counseling 47 (2002) 179185


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problems will never have an evidence-based solution. It

was acknowledged that there are some medical questions

that research has never tackled, particularly in relation to

rare conditions. This was stated by the majority of GPs and

hospital doctors.

. . . there are barriers in terms of the evidence not being

there. Doctors still have to rely on their own clinical

judgement and experience if theres no evidence [GP 7].

There is a general lack of evidence in some specialities,

especially surgery [Hospital Doctor 4].

3.1.2. Scarcity of evidence relevant to patients values

There was also a perception that evidence relevant to

patient values is scarce. Randomised controlled trials

(RCTs) were seen as being conducted only in areas that

doctors considered being important meaning that patients

were not being involved in building up the evidence base.

Non-professionals in particular perceived that this had

resulted in a narrow base of evidence which is not applic-

able to psychosocial problems and does not cover wider

issues such as complementary therapies.

3.1.3. Poor quality of evidence for patients and doctors

Lack of good quality evidence-based information for

patients was also an issue. Written leaflets and internet

information were generally regarded to be poor.

I think the quality of information thats currently

available to patients is on the whole very poor and

not evidence-based. Not only for written leaflets but

also increasingly as the internet becomes a more used

source of information there are big problems about

the quality and reliability of the information there

[Academic 1].

Some doctors stated that the quality of internet informa-

tion for doctors was poor. Frequently reported draw-backs

were: EBM is quickly out of date, not all evidence is

valid and reliable. There were also problems relating to

unfriendly evidence-based sources, exemplified by state-

ments such as it can be laborious to look up the information

as some data sources are not very user friendly and it is

sometimes difficult for doctors to obtain evidence in an

understandable form.

3.1.4. Disease-focused nature of EBM

There were perceived limitations concerning the disease-

centred nature of EBM which does not allow for the

influence of specific characteristics and needs of individualpatients. Evidence-based guidelines were often perceived

as assuming that certain treatments are appropriate for all

patients irrespective of co-morbidity, mental state and per-

sonal circumstances. A common response was that it is

difficult to extrapolate from reductionist evidence to indi-

vidual patients, for example:

Particularly in general practice, its hard to be confident

that what the evidence says applies to the patient that

youre dealing with. The evidence is always statistically

based and the patient is an individual [GP 10].

There was frequent mention of the strict exclusion

criteria in most RCTs and many GPs commented that

the characteristics of those patients excluded were often

characteristics of the patients they had to see.

3.1.5. Interpretation problems

Participants drew attention to problems relating to the

interpretation of evidence. Most GPs thought there were too

many contradictory guidelines and that the evidence con-

tained in some was often disputable.

Theres been all this boo ha ha about the various contra-

ceptive pills and thrombosis and a lot of that has centred

around disagreements about the interpretation of data

. . .the data is agreed, but the interpretation is not

agreed. So what is the evidence base? [GP 4].

3.1.6. EBM limits patient choice

Some participants stated that evidence-based information

limited patient choice by advocating only one appropriate

course of action. In particular, many GPs expressed the view

that following general practice guidelines had precisely this

effect.

. . . weve got a guideline factory going on at the moment

which is counter to choice really, do this, thats not

Table 1

Summary of barriers to the EBPC consultation

Limitations of the evidence

Lack of evidence in some areas of medicine

Scarcity of evidence relevant to patients values

Poor quality of evidence for patients and doctors

Disease-focused nature of EBM

Problems of interpretationPotential for EBM to limit patient choice

Doctor factors

Attitudes concerning the appropriateness of EBPC

Lack of knowledge and skills required for this approach

Patient factors

Lack of desire and motivation to take part in decision-making

Questionable ability to understand the evidence

Resource constraints

The costs of patient choice

The costs of consumerism

The costs of accessing evidence

Time constraints

Time in the consultationTime to access information

Disruption of the doctorpatient relationship

Taking the art out of medicine

Technology hinders the medical consultation

S. Ford et al. / Patient Education and Counseling 47 (2002) 179185 181


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about choice, . . . the main issue there I think is that

choice is driven out by guidelines . . . cos they dont

usually give choices in guidelines, they dont give the

risk/benefit profiles of the options in guidelines, its

working against you see [Academic/GP 11].

The current non-prescribing policy, i.e. antibiotics for

viral infections was frequently cited as an example of

EBM limiting true patient choice.

Patients are sometimes very unhappy with evidence-

based medicine because you get a lot of patients who

come in with a sore throat, for example, expecting a

prescription and then theyre told they dont need a

prescription and they actually go away quite dis-

gruntled [Practice Nurse 2].

3.2. Doctor factors

3.2.1. AttitudesEBPC was seen as dependent on the attitude and will-

ingness of doctors to practice it. In particular, lay people and

academics expressed the view that some doctors were

threatened by the concept of patient empowerment and

feared losing control within the consultation, which made

them unwilling to practice a patient-centred approach.

Linked to this, paternalism and doctor knows best atti-

tudes were seen as strong barriers against the EBPC

approach.

There may be some doctors who do not agree with all of

this (EBPC) and believe that what they say and recom-

mend should be followed at whatever cost. Im thedoctor, Im qualified and who are you to argue with me

about your treatment [Lay Person 6].

There was a fear amongst GPs and hospital doctors that

patients might make the wrong choice, i.e. not in accor-

dance with what they as professionals viewed as the most

appropriate treatment.

I feel quite strongly that okay we can give the evidence

to the patient as we see it, but patients cant force us to

give them the treatment we dont believe in [Hospital

Doctor 4].

3.2.2. Doctors knowledge and skills

GPs and hospital doctors stated that they and their col-

leagues did not always keep up-to-date and found it difficult

to keep on top of the latest evidence.

Many participants expressed the view that doctors lacked

some of the skills necessary for the EBPC approach, spe-

cifically good communication and critical appraisal

skills, the competence to handle statistical information

and ability to explain complex medical information.

Even if doctors are well versed in all the up-to-date

treatments and drugs and surgery available, it doesnt

mean they have the skills to communicate theirfindings

to their patients. They may have all the information

theyve read their medical journals, but theyre unable

to put it into language that patients understand [Lay

Person 3].

3.3. Patient factors

3.3.1. Patients attitudes

There was a general perception held by health profes-

sionals that many patients did not want choice or the

responsibility for decision-making. It was thought for some,

choice can be a burden, some may feel too vulnerable to

get involved and others fear making the wrong decision.

Most GPs and hospital doctors argued that not all patients

felt comfortable with a patient-centred doctor and many

preferred a directive approach instead. Whilst lay people

acknowledged that not all patients wanted to make health

decisions, they felt strongly that doctors should providethem with the opportunity to do so. One practice nurse

was concerned that patient choice might have a detrimental

effect on care if patients decided to discontinue essential

treatment.

3.3.2. Patient understanding

Health professionals also stated that some patients might

be bewildered or overloaded by a full discussion of the

evidence relating to their condition. A common response

was that some patients are not motivated to ask questions

and might not have the educational skills to fully take

part. Health professionals and lay people argued that

patients mental states might render them incapable or

unwilling to make decisions.

. . . I mean I know in making my own decisions that

there are some times when I have not been in a fit state

and I have wanted to hand over the decision to some-

body else um . . . I didnt feel that I could relinquish

responsibility and I did know that I might not agree

with them, but I was incapable because I was in such

emotional turmoil [Lay Person 4].

3.4. Economic/resource constraints

3.4.1. The costs of patient choice

There was a fear from health professionals that patients

might choose the most expensive treatment, therefore

preventing a cost-effective decision. This was closely linked

to concern about economic constraints within the NHS. In

particular, GPs felt that a publicly funded health care system

did not allow for a consumerist model of care and that

patient choice might conflict with limited prescribing

budgets, for example:

I think theres an issue sort of around where some

choices are not really available because they would be



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at a net loss to society, so they are not the cost-effective

option for society . . . and there I think its a lot easier

for practitioners to say well this choice is available, but

you cant have it on the NHS because it has been

decreed at central level that you cant [Academic 5].

3.4.2. The costs of consumerism

Evidence-based guidelines were regarded as having the

potential to push up the cost of health care if the evidence

pointed towards expensive drugs being the most effective or

advocated the treatment of conditions previously untreated

by the medical profession, for example, several GPs cited the

case of statins now routinely prescribed for individuals at

high risk of heart disease. Contraceptives were also men-

tioned in relation to costs.

I work a lot with students and one of the things is the

introduction of new emergency contraception, and that

has huge costing implications, but the research has

shown its effective and you have to advise them in that

respect [Practice Nurse 4].

3.4.3. The costs of accessing evidence

There were strong views amongst GPs that the technical

resources, i.e. equipment required for an evidence-based

approach including electronic link-ups to the evidence, were

lacking, particularly for those GPs at grass roots level.

The infra-structure and level of investment in general

practice was frequently judged to be insufficient for imple-

menting the EBPC approach. In general, the financial com-

mitment to training doctors how to practice EBM was

regarded as inadequate.

I think it will become easier when the information

technology era hits general practice, but thats a decade

away. Were lucky in academic contexts because we can

get to Medline and the Web but, when Im at my desk in

the practice, Im a decade behind because the infra-

structure and investment hasnt been made there. I long

for the day when I can turn to the patient and say lets

just look this up now [Academic/GP 11].

3.5. Time constraints

3.5.1. Time in the consultation

Bringing formal evidence into the consultation posed

problems in terms of not having enough time to explain

and discuss it with patients. The amount of time available for

doctors and patients to absorb the evidence was commonly

regarded as very limiting, for example:

We are under a lot of pressure to see patients within

30 min of their appointment time. If you are trying to

explore patients concerns, . . . it isnt always easy to

explore those concerns and understand them in the

right time frame. A lot of patients quite rightly want to

spend a lot of time with their doctors because they find

that it gives them confidence, more understanding and

its therapeutic as well and then the barrier is the time

[Hospital Doctor 1].

3.5.2. Time to access information

GPs in particular felt that it was too time consuming tolook up evidence for certain conditions during routine

surgeries. Large case loads and other clinical pressures were

cited as reasons against implementing the EBPC approach.

Theres an art to making time to access the body of

evidence because its really difficult for grass roots

general practitioners to access that on a regular basis. I

mean for the common conditions that theyre working

with on a daily basis they will have a grounding any-

way, but there are things daily that strike a question and

you just havent got time to Medline everything. So that

is an issue [Academic/GP 11].

3.6. Disruption of the doctorpatient relationship

The majority of responses for this theme were related to

evidence-based consultations taking the art out of medi-

cine and making doctors seem less interested in patients

as people or individuals. There was also the concern that

this type of approach might undermine the placebo/ther-

apeutic effect of the consultation.

There could be interference with the dynamic of the

consultation, you dont want figures to . . . if youre

quoting evidence it certainly can destroy the atmo-

sphere and the tone of the consultation. It shouldnt be

imposed [Hospital Doctor 5].

Practical issues were also mentioned such as the potential

for computers on GPs desks to interfere with the doctor

patient interaction. For example, loss of doctorpatient eye

contact could make patients feel excluded or ignored.

4. Discussion

If progress is to be made towards patient empowerment

it will be important to identify the various barriers to its

implementation as a preliminary to trying to overcome

them. We have sought to do this through a systematic

qualitative study of the barriers to one specific model of

patient empowerment, EBPC. Several of the barriers iden-

tified are being addressed, whereas others have received less

attention.

Some of the drawbacks expressed in relation to the

evidence accord with previous studies, which report a lack

of available research evidence and the failure of EBM to take

into account the contextual elements of decision-making

[14]. There was also concern from participants that research

questions important to patients were not being addressed



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thus, resulting in a narrow evidence base. Proponents of

greater lay involvement in health research emphasise that

patients and other lay people often have insights and exper-

tise that complement those of health professionals and which

could improve the quality and impact of research [18].

In fact, lay involvement is increasingly being called for,

particularly in relation to pregnancy and childbirth [19].Furthermore, the National Health Service Research and

Development Programme is committed to reflecting the

concerns of consumers throughout its work [20].

Misgivings about the quality of evidence-based patient

information materials are borne out by recent studies. The

majority have found that few sources meet patients infor-

mation needs in terms of presenting information about the

range of relevant treatment options, and providing a non-

biased, evidence-based view of the effectiveness of each

treatment [21]. Furthermore, although the medical informa-

tion available on the World Wide Web has proliferated at a

remarkable rate, the number of sites providing complete

non-biased information continues to represent only a small

portion of the total [22,23]. Encouragingly, newly developed

and validated tools such as DISCERN and the Health

Information Quality Assessment Tool now enable users of

health information (Web-based and written) to assess the

quality of these sources [24].

A common concern expressed by participants was that

EBM might work against patient choice especially if evi-

dence-based guidelines were strictly followed. This is sup-

ported by a recent study of 97 patients with atrial fibrillation

[25]. By eliciting preferences and performing decision

analysis the number of prescriptions for Warfarin desired

by these patients was reduced by 40% of the total numberadvocated by management guidelines.

Barriers specific to doctors included a lack of skills to

practice the EBPC approach. Previous studies have found a

reluctance and a lack of perceived need by GPs to acquire the

necessary critical appraisal skills required in order to access

and apply evidence to patients [26,27]. There are many

courses designed to teach these skills and enable doctors

to practice EBM [28]. Primary care groups and trusts will

need to invest in information technology to enable doctors to

get in touch with the evidence base and speed up their

practice. In a recent survey of 302 English GPs, only 20%

had access to Medline or other bibliographic databases and a

mere 17% had access to the World Wide Web [26]. Innova-

tions such as the Cochrane Collaboration [29] and the

recently launched National Electronic Library for Health

(NeLH), aim to provide health professionals and patients

with easy access to the most up-to-date evidence of the

effectiveness of health care interventions, but such informa-

tion is still relevant only to a relatively small proportion of

consultations [30].

The perception that patients do not wish to be involved in

medical decision-making is unproven. Many of the studies

evaluating patient preferences for participation use hypothe-

tical scenarios and the decisions relate to severe conditions

such as cancer [11,31]. Few studies investigate patient desire

for involvement in decisions about relatively minor medical

problems.

Economic and resource constraints were seen as signifi-

cant barriers to patient choice. This is contrary to the view

that EBM reduces healthcare expenditure by eliminating

ineffective or inappropriate interventions [3]. In cases wherethe NHS is unwilling to pay for certain treatment options

true patient choice may be constrained. This raises the issue

of whether health professionals should present information

to patients about the options available within the NHS or all

of the possible options.

Lack of time was also commonly viewed as a major

barrier to the EBPC consultation, i.e. the limited amount

of time available during the consultation both to look up the

evidence and to discuss options with patients. In a previous

qualitative survey of 20 GPs working within the Avon Health

Authority [32], half the GPs reported having no time to do

what they perceived as extras, such as evaluating informa-

tion or keeping up-to-date. Due to feeling constantly time

pressured, they felt unable to use consultation time for

activities such as in-putting or retrieving electronic informa-

tion. Possible solutions include extended consultation times

or information and support being provided to patients out-

side the traditional doctorpatient encounter [5].

Although alluded to in Section 3.2.2, other barriers within

the consultation which were not specifically mentioned

include more intricate problems concerning how profes-

sionals can either be skilled or not at involving patients.

Interpersonal skills and the information requirements

needed to successfully share decisions are major challenges

to the medical consultation process [6].Tensions between patient-centred care and EBM will

persist as long as health professionals see themselves as

having to fulfil a double role [33]. On the one hand they are

expected to be scientists who critically appraise and apply

the best available evidence and on the other they are

expected to be sensitive caregivers. However, as Bensing

suggests, by strengthening the patient-centredness of EBM,

for example, by incorporating patient values into clinical

guidelines, it may be possible to benefit patients and dimin-

ish professional tension caused by the dual role [2].

Furthermore, by ensuring patient involvement becomes an

accepted and integral part of evidence-based decision-mak-

ing, the division between scientific medicine and patient-

centred choice will gradually erode.

4.1. Study limitations

The participants comprised knowledgeable individuals

(some of whom were medical student tutors) who were

generally motivated towards new innovations in medical

practice. In this respect their views are highly selective.

However, it is possible that the presence of the researcher, a

health psychologist may have influenced the responses of

some of the participants. For example, some may have been



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reluctant to express negativeviews in order not to appear anti

EBPC whereas others may have emphasised the drawbacks

to please the observer. Every effort was made to reassure

participants that we were interested in their own personal

opinions what ever they might be.

4.2. Implications for practice

If EBM and patient choice are to work together in future

healthcare practice, then the barriers identified in this study

will need to be tackled. Those barriers already receiving

attention have been highlightedmost notably doctor and

patient access to good quality evidence. However, barriers

that have received relatively little attention relate to the

processes of care. These include clinical guidelines that are

not sufficiently flexible to allow for variation in patients

values, and that inhibit patient choice, and lack of consulta-

tion skills and time needed for the integration of this

approach into the medical consultation. Future steps towards

integration must include providing health professionals

with the knowledge and skills needed to practice the EBPC

approach, thereby enabling them to routinely involve patients

and offer unbiased choices.

Acknowledgements

We thank all those who gave up their time to be inter-

viewed and our colleagues who gave advice throughout the

study, in particular Professor Paul Salkovskis and Joyanne

McInnes. This paper forms part of a project funded by the

NHS Anglia and Oxfordshire Regional R&D.

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Documents

Barriers to the Evidence-based Patient Choice (EBPC) vs EBM. Paper Study. Evidence based medicine interest