General practitioners' perceptions of the effectiveness of medical interventions: an exploration of underlying constructs

BACKGROUND Many interventions shown to be effective through clinical trials are not readily implemented in clinical practice. Unfortunately, little is known regarding how clinicians construct their perceptions of the effectiveness of medical interventions. This study aims to explore general practitioners' perceptions of the nature of 'effectiveness'. METHODS The design was qualitative in nature using the repertory grid technique to elicit the constructs underlying the perceived effectiveness of a range of medical interventions. Eight medical interventions were used as stimuli (diclophenac to reduce acute pain, cognitive behaviour therapy to treat depression, weight loss surgery to achieve weight loss, diet and exercise to prevent type 2 diabetes, statins to prevent heart disease, stopping smoking to prevent heart disease, nicotine replacement therapy to stop smoking, and stop smoking groups to stop smoking). The setting involved face-to-face interviews followed by questionnaires in London Primary Care Trusts. Participants included a random sample of 13 general practitioners. RESULTS Analysis of the ratings showed that the constructs clustered around two dimensions: low patient effort versus high patient effort (dimension one), and small impact versus large impact (dimension two). Dimension one represented constructs such as 'success requires little motivation', 'not a lifestyle intervention', and 'health-care professional led intervention'. Dimension two represented constructs such as 'weak and/or minimal evidence of effectiveness', 'small treatment effect for users', 'a small proportion of users will benefit' and 'not cost-effective'. Constructs within each dimension were closely related. CONCLUSIONS General practitioners judged the effectiveness of medical interventions by considering two broad dimensions: the extent to which interventions involve patient effort, and the size of their impact. The latter is informed by trial evidence, but the patient effort required to achieve effectiveness seems to be based on clinical judgement. Some of the failure of evidence-based medicine to be implemented may be more explicable if both dimensions were attended to.