1. Can I trust the recommendations?
A common predicament for the GPs when assessing guidelines was a lack of trust in the recommendations. The most evident source of distrust among the participants was the concern that economic motives may overshadow clinical considerations. The participants feared that government guidelines designed for cost control and rationing are clinically unsound and do not recommend best practice or adequate health care. It was suspected that hidden economic motives often lie behind guidelines. However an explicit rationing motive was regarded as acceptable.
I think this is moving the focus away from the patient and towards a set of rules which is not about patients but about money.
(Male GP, Oslo)
GP: I am concerned that money is all too important. I am afraid the economic issues will overshadow other important values.
Researcher: That economic issues are included in the decision without your being aware of it?
GP: Yes, that that is what lies beneath it all.
(Female GP, Oslo)
I think it's reasonable from the authorities' side to have guidelines which say we have economic boundaries, which mean we can't do everything we could, but then it should be stated that that is what is happening. And there aren't many people who dare to say that. So I am worried that guidelines come out with an underlying agenda which we don't get to see.
(Male GP, Oslo)
Some of the participants found it difficult to "sell" cost-cutting guidelines to patients, while others said that, in the end, patients would understand and follow doctors' advice if they were explicitly informed about cost issues. Both these points of view suggest that the doctor's own attitude to guidelines often is transmitted to the doctor-patient relationship. The doctor's own suspicion of a hidden agenda of cost control was seen as a problem when the doctor had to negotiate new routines with patients, whereas if the doctor had accepted and understood the guidelines, this also seemed to be reflected in patients' attitudes.
But it is worse with medicines for blood pressure, and then sometimes I think it's a hassle to have to start everyone on thiazides. And then I'm maybe a bit biased so that patients notice. So they get the side effects they expect so we can put them on the other drugs.
(Female GP, Oslo)
I see that people think it seems quite reasonable. If the drugs are just as good, and I say we have been told to use it to save a couple of million kroner a year. Then they say, yes, that's fine.
(Male GP, Hordaland)
Sometimes GPs agreed with health authorities that rationing is necessary and that economic considerations should, therefore, be part of the guideline basis. Nevertheless they had little faith in the economic evaluations behind specific guidelines. They were suspicious that the economic evaluations had been too simplistic, i.e. not including any extras that the implementation of the guideline would entail, or they were doubtful that the health authorities could be trusted to use savings in other more important areas.
The problem with this type of guidance from the state medicines agency is that nobody counts the extra doctor time used. How much extra treatment costs does the welfare office get for appointments and fees for doctors using time on this? It may not be very much, but it will outweigh a good part of the effect, and we can't see that health economists have looked at this.
(Male GP, Hordaland)
It's easy to see the importance of using the right medicines, but it's clear that part of the problem with, for example, reimbursement of drugs is that it appears very random and unfair. When the state medicine's agency says no, the industry goes to the parliament (...) and gets them to speak up for a medicine with little effect. It obviously seems a bit dumb that I'm supposed to sit here in my practice and change all my patients to a cheaper copy of the drug for the state to save money which it then doles out at random to huge pharmaceutical companies.
(Male GP, Hordaland)
Fear of economic motives led to distrust of both governmental and pharmaceutical guidelines albeit for very different reasons. The GPs frequently referred to the conventional truth that recommendations and courses sponsored by the industry are driven by a chase for profit and cannot be trusted. Some even said that they refused to read such recommendations.
They both have their agenda. The pharmaceutical industry is for profit and the state wants to save money. So in a way it's two sides of a money issue.
(Male GP, Hordaland)
If the pharmaceutical company has financed it, it goes in the bin unread. Even if it might be very good. And much the same applies to certain guidelines from the state. Because the state medicine's agency has a one-sided focus on saving money. You can't always trust what comes from there.
(Male GP, Hordaland)
In contrast to the scepticism towards proscriptive (regulatory) guidelines from health authorities or the prescriptive (innovative) guidelines from the pharmaceutical industry, guidelines developed by general practitioners were unanimously trusted. The guidelines GPs claimed most adherence to were treatment programmes which were developed by general practitioners or by a multi-disciplinary group that included general practitioners. This was seen both as a guarantee that the guidelines were not economically motivated and also that the authors were familiar with the complex reality of general practice.
I feel that the further they are from us, from knowing what daily life is like for us, the less faith I have in them. I have most faith in what is presented by those who know what our every day is like.
(Female GP, Oslo)
Clearly something which is done as a voluntary effort, for free, by Norwegian GPs, I have great faith in.
(Male GP, Hordaland)
For the GPs to believe in the recommendations, it seemed necessary that they trusted the evidence behind the guidelines. The participants were sceptical about transferring evidence produced in population based studies or hospital based experiments to general practice and individual patients. Many were of the opinion that guidelines developed by hospital specialists had little relevance to general practice and that possible side-effects were often not sufficiently examined. Others had more faith in the specialists' recommendations and were happy to leave some of the responsibility for clinical decisions to those who they assumed had better knowledge of the evidence.
Yes, we don't really know much about how it is for that particular person. This is aggregated data, and we don't know anything about what the individual's risk level actually is. We can try to work it out, but it is based on statistics.
(Male GP, Hordaland)
It's not certain that the gain is as great as we think. They haven't done studies on this population. Guaranteed not. Studies can be done for populations with higher risks than the normal population. There has to be someone sick to be able to measure the difference.
(Male GP, Hordaland)
I think you maybe feel a bit of a need to believe (in guidelines). I have to believe some of what comes from the sources we trust. Because there are so many choices, I feel, in this job. And then it's a bit like sharing some of the responsibility in a way.
(Male GP, Oslo)
A recurring theme in the interviews was how to relate to the fact that recommendations are constantly changing and evidence often debated, reflecting disagreement among the experts. Generally the participants accepted that guidelines are changing and preferred guidelines that were constantly updated, and they saw open discussion as an advantage which increased trust in the guidelines. Hence it was vital that they had had the opportunity to familiarise themselves with the evidence. On the other hand the same participants also sometimes said that they found expert disagreement confusing, especially if they had not had the time to assess the evidence themselves.
Some pointed out that disagreement and debate is positive also because it suggests that it is legitimate to be critical to the recommendations. Others had the opposite reaction; in cases where there is a lot of disagreement about what is best practice, it is safer and easier to stick to the guidelines.
Well, it's not just one person sitting giving their opinion. It's a discussion and a process the whole time. That gives me more faith in it.
(Male GP, Oslo)
GP1: Discussion is an advantage.
GP2: Yes, it confirms that we are involved in an academic discipline, not just some kind of slavery.
GP1: Yes, that we have to listen to differences and then we have our own experiences. When we have treated 100 patients with blood pressure drugs, we get a bit of a feeling of what gives side-effects and what is effective reducing blood pressure.
(GP1: Female GP, Oslo; GP2: Male GP, Oslo)
I'm pretty gullible. I believe everything I hear! (laughs). I believe in a way what is written in the Norwegian medical journal. That I believe. Right until someone writes some weighty critique of those articles which makes me realise, 'Oh, so that wasn't quite right at all then?' So, what I like is maybe places where you see that it's a discussion, the way it is in the journal. It's, in a way, open, a place where you get research and theories presented, but there's a chance for others to come with counter-arguments. And they do that to a large extent. And that makes me, in a way, a bit secure that here you get all kinds of opinions, and if something is completely wrong, then if I read the next journal, I'll realise.
(Female GP, Oslo)
2. Are the recommendations consistent with this patient's needs?
A recurring theme in the interviews was whether following the guidelines would allow the individual patient's needs and expectations to be fulfilled. The GPs emphasised that they had first hand knowledge of the patients' ailments, expectations of the consultation and life circumstances. People's anxiety about potential health problems and their knowledge about the possibilities for screening and treatment as well as about their rights as patients were frequently discussed in the groups as potential obstacles to adhering to guidelines. Some patients were seen as demanding and several participants emphasised a desire to get patients' appreciation. In the participants' experience, the aim of satisfying patients frequently conflicted with adhering to guidelines. On the other hand a few GPs reported that they referred to guidelines to avoid having sole responsibility for uncomfortable rationing decisions.
If we want to survive. If we are going to find a solution for the patient sitting opposite us, we have to compromise on a lot of these guidelines. We have after all learnt to sniff our way forward to what is possible and maybe what is best for the patient. Even if we don't follow all the guidelines.
(Male GP, Hordaland)
And patients have their own preferences too. Regarding use of medicines, what symptoms they can tolerate, and what level of blood pressure, what risk they are willing to take, how they are willing to let medication influence their life and what medicines they are prepared to take.
(Male GP, Hordaland)
The situation where guidelines recommended more treatment than the GPs or the patients themselves deemed suitable was discussed less. In some cases GPs said that they respected and understood patients' wishes to abstain from treatment.
I had a patient. He was nearly 80 years old and a bit confused, but I had the discussion. Shall we try Maravan? And I put forward the arguments for and against, that you can reduce the risk of brain haemorrhage, but on the other hand, if you start messing about with your medicines, that can be risky too. We agreed after a very pleasant discussion that we would use Albyl instead. It is not so well documented, but it was acceptable, and then you avoid a blood test every four weeks. So I felt that was very meaningful, and the patient lived several more years and died of something completely different.
(Male GP, Hordaland)
Guidelines are often very schematic, and life isn't always so simple and so you have patients who are very sceptical about medicines or who have been allergic to loads of stuff, and would rather not have it even if the guidelines say they should. ... There is something about life not being so simple that you can slot it into a framework. You have to have a bit of understanding for that, have a dialogue with the patient, and try to work towards a solution that functions, and sometimes that isn't quite according to the book.
(Female GP, Hordaland)
3. Is following the recommendations feasible?
The participants reported busy days in their practices. They felt there was no time to update oneself on the medical literature or on the evidence behind the guidelines or perhaps even to read guidelines. During consultations the GPs depended on the guidelines being quick and easy to look up and read. Following the recommendations was often regarded as too time consuming if it involved explaining or convincing patients. Some also noted that it is sometimes difficult to make patients accept a change in guidelines, especially when patients are used to a treatment that is no longer recommended.
There is a lot of good work behind the formulation of these guidelines. But they become so detailed that I can't remember more than a little. Can always look it up, but you don't have time when you sit there with a patient or you are already a bit behind schedule.
(Male GP, Hordaland)
It's clear, when you change guidelines, like with these allergy medicines, which came into force on the first of May, in the middle of the worst pollen season, and where specialists have a practice where one medication has been preferred, and most of the patients are on it. And then, first, patients ring to order a repeat prescription, and you have to argue that they should try some other things first, then you have to check if they have used it, you have to test it out, whether it works as well or if there are side effects, and then you have to write an evaluation in the record, and then, if it for one reason or another didn't work properly or had side effects, you can change back again. You find yourself having to argue it out every time you write a new prescription. There is a terrible amount of extra work in that!
(Female GP, Hordaland)
In general participants thought that GPs should be informed about which guidelines to follow and where to find them. They had no time to search the internet for guidelines and their revisions. They found it difficult to find the relevant guidelines since they appear in different sources.
The regulations for reimbursement of medicines are pretty complicated. It takes a lot of time to understand them. The worst thing is that no-one sends them to you. You just have the responsibility of reading them on the internet and you don't even know what you have to read.
(Male GP, Hordaland)
You don't have time after a 50 hour working week to sit in the evenings and read on the internet.
(Female GP, Hordaland)
Among existing guidelines the GPs preferred those that were easy accessible. The format should be short and simple enough to read in a short time, albeit comprehensive enough to be convincing. Guidelines with access to updated and graded recommendations, depending on the strength of the evidence base, were both easier to trust and easier to "sell" to patients. Electronic sources were generally rated positively for their easy access and convenience when looking up a specific problem or guideline. One advantage of electronic sources was that information could be checked without the patient being aware of it, which made it easier to be convincing. Many mentioned the need for patient leaflets.
In addition, the process of implementation was discussed several times. A transparent process demonstrating the rationale behind the guidelines with a thorough introduction was preferred.
The good thing about NEL (Electronic Handbook for Norwegian Doctors) is that it gets updated. You know they are written by GPs for GPs. They write up the references. And it is built up in a way that suits the way we work everyday. If we know what it is, wonder if there is anything new in the treatment, we can just click to it and get straight to the chapters. It's easy.
(Male GP, Hordaland)
(About guidelines on antenatal care) They have credibility. Partly because they have graded the strength of the advice. Where the documentation is weak, they are cautious. Where the documentation is strong, they are more definite (...) They look systematically at the validity of the research and that also allows us to evaluate each recommendation, how much weight we should put on it, how much we should be inclined to follow it. So that for me is an example of a pretty good guideline. A process which allowed for discussion.
(Male GP, Hordaland)
I think most of us have pretty limited time to go systematically through new evidence (...) An easy to use format will have more effect than one which is not so easy to use. Regardless of whether is has a sound basis or is reasonable.
(Male GP, Hordaland)