Psychiatrists' views of evidence based psychiatric practice

Aims and method To determine the attitudes of psychiatrists towards the practice of evidence-based medicine by use of a postal questionnaire. A survey was sent to Consultant Psychiatrists and to Higher Trainees in Psychiatry in the West of Scotland Region.

Results While older influences on decision-making such as tradition and deference still play a part, almost all respondents consider the adoption of more effective care based on best available external evidence desirable; most think it attainable. The technology is generally available, but further training is desired to access the information and its critical analysis.

Clinical implications Educational activities should increasingly focus on skills for data search and critical analysis.


Psychiatrists' views of evidence based psychiatric practice
Stephen Carey and David J. Hall Aims and method To determine the attitudes of psychiatrists towards the practice of evidence-based medicine by use of a postal questionnaire. A survey was sent to Consultant Psychiatrists and to Higher Trainees in Psychiatry in the West of Scotland Region. Results While older influences on decision-making such as tradition and deference still play a part, almost all respondents consider the adoption of more effective care based on best available external evidence desirable; most think it attainable. The technology is generally available, but further training is desired to access the information and its critical analysis. Clinical implications Educational activities should increasingly focus on skills for data search and critical analysis.
Evidence-based medicine is "the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients" (Sackett et al. 1996). In its practice the clinician must define the clinical question to be answered, search for the evidence, appraise it and apply it (Geddes & Harrison. 1997). It has been highlighted that 'evidencebased' decision-making may be subject to pre-existing beliefs and an unconscious filtering of even the best evidence (Anderson, 1997). and that a technology is required (Sheldon & Gilbody, 1997). It has been suggested that new evidence is required (Lewis. 1997), with new clinicallyrelevant, randomised controlled trials. Never theless it has been suggested in one study that evidence was identified to support 53% of psychiatric interventions (Summers & Kehoe, 1996) and a recent editorial has indicated the benefits of structuring journal clubs along evidence-based lines (Geddes, 1998). General practitioners have been shown mainly to wel come evidence-based medicine, and to adopt it in a substantial part of their clinical practice (McColl et al, 1998). Clinicians may, however, base decision-making instead on tradition, clin ical intuition or deference to a senior colleague (Schmidt et al, 1996).
In the recent Scottish Office White Paper Designed to Care -Reviewing the National Health Service in Scotland, the Government is "promoting the adoption of more effective care based on evidence". In this study we sought the views of consultant psychiatrists and senior registrars (SRJ/specialist registrars (SpR) in psychiatry, in the West of Scotland, concerning the practice of evidence-based psychiatry.

The study
A questionnaire, designed for the purpose, was posted in March 1998 to the 169 consultant psychiatrists working in the National Health Service in the West of Scotland, identified from information provided by the Information Services Division of the Scottish Office, and to the 47 SR/ SpRs in psychiatry working in the Region, identified from the Rotational List published by the Regional Training Committee (Committee in Psychiatry. 1998).
Evidence-based medicine using the best avail able external evidence, was at present felt to be very or quite useful in decision-making about patients in psychiatry by 90 consultants (84%) and 30 SR/SpRs (97%). Clinical intuition was regarded as very or quite useful by 93 consul tants (87%) and by 30 SR/SpRs (97%). Opinions varied on the value of tradition with 52 con sultants considering this to be very or quite useful (49%) and 18 SR/SpRs (58%).
Interestingly, higher trainees exceeded their consultants regarding the value of deference to a senior colleague in decision-making.
Twentynine of the SR/SpR group considered this to be very or quite valuable (94%), but only 50 consultants (46%). Discussion with colleagues was valued in both groups: 104 consultants (96%); 30 SR/SpRs (96%). Journal reviews were also widely valued, with 103 consultants (95%) Regarding evidence-based skills. 50 consul tants (46%) felt they had good data search skills, and 21 higher trainees (68%), but almost all wanted to improve them further. Fifty-seven consultants (53%) felt they had good skills in analysing data, but only seven trainees (23%). However, almost all in both groups wanted also to improve their skills in this area.
We next asked about access to, and use of, sources of information. Only 29 consultants (27%) had an accessible office-based personal computer with access to an electronic database such as Mediine, and only three trainees (10%). An office-based personal computer was used often by 28 consultants (27%) and six trainees (19%). However, a library-based one was found to be accessible by 86 consultants (80%) and 30 trainees (97%). Trainees used the library com puter more often (n=21, 68%) than consultants (n=28, 26%). Up-to-date textbooks remain a valuable source of information, being accessible to 95 consultants (88%) and 23 trainees (74%). They are reported as used often by 61 consul tants (56%) and 22 trainees (71%). Up-to-date journals with literature reviews are accessible to 103 consultants (95%) and 28 trainees (90%). They are reported as used often by 86 consul tants (80%) and 26 trainees (84%).
Continuing Professional Development is a current area of debate for consultants. In this group in the West of Scotland, 71 were registered (66%). Among this number, difficulty in meeting the requirements for Module B (participatory learning) was recorded in 23 (32%) and for

Consultants (n= 108) SR/SpRs (n=31 )
Evidence-based medicine rated very or quite useful in decision-makingClinical intuition rated very or quite usefulTradition rated very or quite usefulDeference rated very or quite usefulDiscussion with colleagues rated very or quite usefulJournal reviews rated very or quite usefulHave good data search skillsWould like to improve data search skillsHave good skills in the critical analysis of dataWould like to improve critical analysis skillsOffice-based computer with database accessibleOffice-based computer with database used oftenLibrary-based computer with database accessibleLibrary-based computer with database used oftenUp-to-date textbooks accessibleUp-to-date textbooks used oftenUp-to-date journals accessibleUp-to-date journals used oftenAdoption of more effective care based on evidence desirableAdoption of more effective care based on evidence attainable90 Module C (local events such as case conferences) in 16 (23%). Fewer experienced difficulty in meeting the requirements for the other modules. Of those not registered many (n=14. 42%) intend to, but some (n=9, 27%) are unsure. Almost all consultants (n=102, 94%) and high er trainees (n=30, 97%) felt that the adoption of more effective care based on evidence was a desirable goal. Fewer, however, thought it was attainable: 72 consultants (67%) and 23 higher trainees (74%).

Comment
The practice of psychiatry in an evidence-based way, using the best available external evidence, is considered desirable by almost all consultants and higher psychiatric trainees in the West of Scotland, and most think it an attainable goal. However, older influences on decision-making including tradition and deference still play a part, and those responding may tend to adopt evidence-based practice more than others. There is a desire to improve skills in evidence-based psychiatry. Though we still value texts and journals, newer technology is, mostly, available, and this study indicates Continuing Professional Development is gaining acceptance. The West of Scotland is moving towards a more evidencebased practice of psychiatry.

Liaison-consultation meetings in general practice
An audiotape analysis

Rebecca J. Tipper and Ian M Pullen
Aims and method Audio-recordings were made over a period of six months of liaison-consultation meetings between general practitioners and a community mental health team in the Scottish Borders to show general trends in length of discussion and information exchange.
Results Meetings were predominantly supportive, with high levels of shared information, but little educational content. Some trends in discussion time are shown. Clinical implications Audio-recording could form the basis for reviewing the function of liaison-consultation meetings.