Why do residents fail to answer their clinical questions? A qualitative study of barriers to practicing evidence-based medicine.
OBJECTIVE
Physicians fail to pursue answers to most of their clinical questions, despite exhortations to practice evidence-based medicine (EBM). While studies have revealed several barriers practicing physicians experience in answering clinical questions, residents may encounter unique obstacles. The authors conducted a qualitative study to explore residents' experience in trying to answer their clinical questions.


METHODS
In 2003, the authors studied a convenience sample of 34 residents, representing 54% of the residents in a university-based internal medicine program. A professional facilitator convened and audiotaped three focus groups with the residents, following a discussion guide. The key question elicited the barriers residents encountered in attempting to answer their clinical questions. A thematic analysis of the transcripts was performed, using the constant comparison method of analysis. Two investigators met after independently analyzing each of the transcripts to compare coding structures, review theme exemplars, and reach consensus for differences.


RESULTS
Eight main themes emerged that characterize the EBM barriers, including access to medical information, skills in searching information resources, clinical question tracking, time, clinical question priority, personal initiative, team dynamics, and institutional culture. The analysis suggested a conceptual model in which residents may encounter different barriers in every step of the EBM process. Furthermore, attitudinal or cultural barriers may lead a resident to abandon the pursuit of a question before some of the technical barriers would be encountered.


CONCLUSIONS
Residents face several EBM barriers, some of which are unique to their status as trainees. While increased informatics training and reliable, rapid, and point-of-care access to electronic information resources remain necessary, they are not sufficient to help residents practice EBM. Educators must also attend to their attitudes toward learning and to the influence of programmatic and institutional cultures.
Green
Michael L
ML
Yale Primary Care Residency Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA. michael.green@yale.edu.
Ruff
Tanya R
TR
D000328:Adult; D035843:Biomedical Research; D003237:Connecticut; D019317:Evidence-Based Medicine; D005260:Female; D017144:Focus Groups; D006801:Humans; D016247:Information Storage and Retrieval; D007388:Internal Medicine / Q000193:education; D007396:Internship and Residency; D007400:Interprofessional Relations; D008297:Male; D008490:Medical Informatics; D009042:Motivation; D015279:Organizational Culture; D010347:Patient Care Planning; D010348:Patient Care Team; D012494:Sampling Studies; D013997:Time Factors