Table 3 Quotations: Constraints on practice

"I fear that what's happening with evidence-based medicine is that it's becoming a rigid system and the push behind evidence-based medicine in certain quarters, not all, has to do with money and not with care... There is less of an understanding on the part of management of the actual work circumstances for those of us on the care end that are trying to implement it." FP04

"I think my practice is more evidence-based than it was because the information is more widely available. I guess the difficulty is that when I'm seeing patients, I don't want to be totally constrained by this idea that the only thing you can do in any one encounter is what's defined by a guideline, and if it's not defined by a guideline, then you can't do it." FP03

"I think evidence-based medicine is being over-emphasized. We're losing the art of medicine.... We're becoming too much like paper pushers and computer geeks instead of recognizing the humanity, especially with family physicians who see the people through everything." FP07

"I think the fear that I have about evidence-based medicine is that it's asking us not to think any more. If somebody else is going to go, "Okay, we've looked at the evidence and this is what you do," then I'm becoming more of a technician than a practitioner. I do think that there's still a place for us to be critical of evidence." FP04

"The guidelines will only take you so far and they're a useful stepping off point, but each individual case has so many factors at play beyond what the guidelines cover and that's where the art and the pleasure of medicine comes in using your clinical judgement to realize that what the protocol says doesn't apply to that person or it applies in a different way. That takes a good understanding of what the meaning is behind the protocol so I don't think you're ever just a technician." FP01

"The way it's presented is: 'This is what you do. If this is here, you do that.' That's not the way we can practice medicine and they have to realize that." FP10

"I have to say that, probably because I practiced before it came along, I know that most of the things that I do are not evidence-based... Personal experience means a lot and it's hard to get away from that when you're faced with an evidence-based pronouncement that says that a certain thing that you do for somebody isn't useful, even though you've used it in the past and found something that you wouldn't have found if you hadn't done it." FP03

"Another frustration would be that when a patient doesn't respond well to a certain therapy, then we need to use other therapies, but there may or may not be evidence for that. Then sometimes we're checked or doubted for our competency if we do things not quite in the norm." FP07

"We get mail-outs of clinical practice guidelines which are evidence-based – they're really looked at as recommendations for treatment. None of us feel like we have to do things this way, but we also know that we have information on a simple sheet to back up where the evidence is." FP08