Table 6 Quotations: Patient factors

"Sometimes it's hard to sell it [the evidence] to certain patients. They have a certain expectation and one of the principles of family medicine is to be patient-centred. You have to listen to what they have to say and then meet in the middle... Often it's a struggle and I find that I'm delaying treatment because the patient is not willing to accept the evidence" FP09

"I try to explain the evidence to them as best I understand it, and then we end up doing what the patient wants to do most of the time." FP05

"It [EBM] has to be another layer of thinking, I suppose, but when it comes to whether or not it's in the patient's best interest to do it, the evidence-based stuff often goes out the window.... I think it's useful to have it as a guideline, but it's difficult sometimes when you think you're in the hot seat trying to deal with a patient's needs. You don't want to let your patient down... and sometimes that's a difficult task to accomplish, to have the patient go away feeling that their concerns have been addressed." FP03

"Sometimes, in order to keep the peace, you may deviate from the evidence to appease the patient. You have to do that sometimes because you're living in the real world, you're interacting with people. The trick is to know how far you can deviate." FP13

"EBM is helpful to give physicians a reference on how to manage cases, but it depends on the personality of the patient. When I know the patient, they're usually willing to accept it [the evidence]. It's important to earn the trust of the patient first." FP15

"Evidence-based medicine has probably been over-focused on the scientific data aspect and less about how to incorporate that in the context of the patient's values and wishes and the particular clinical circumstances of a given individual patient." FP02

"Patients are now accessing the Internet and coming in with decisions about what's wrong with them. With a certain set of symptoms, one would follow a certain protocol for testing, but sometimes now patients have ingrained in themselves the idea that they have to have this [particular treatment], and there's no amount of discussion that will budge the feeling that that's what they've got. So, in that circumstance, I will sometimes order the test they're asking for, even though they don't fit the protocol, because that's the only way of showing to them that that firmly held belief that this is what's wrong with them isn't what's wrong with them." FP04

"What I explain to my patients is that my job is to give them advice, and my advice is based on the best evidence and skill that I have, and then once they listen to my advice, they have to make up their own mind and take my advice and do whatever they want with it. If they insist on having something more aggressive done that I don't agree with, then I'll often set up for them to get a second opinion." FP08

"I often negotiate with the patient. If there's some kind of end-point we're looking at, depending on what they're wanting to do, and if it seems reasonable and non-harmful, I'll often go along with something I normally wouldn't, for a while anyway... I think it really depends on the situation. I think the bottom line is looking at what's more harmful to the patient. I really try to talk with the patient about it beforehand That's where the art comes in. If the patient is very articulate and has read up on different information, then I'll go along with it to a point, but I won't go against my own ethics or the College ethics." FP07

"The evidence that new drug XYZ is going to reduce the incidence of death by one percent really doesn't matter if my patient can't afford the basic... If it's something like a minor improvement for a great deal of money, I won't even tell the patient. What's the point? I know they can't afford it." FP05

"What is it that you want to achieve? Are you looking at quantity of life or quality of life? And how do people value of quality of life? What's important to them? Those are things that need to be factored in. If you specifically want to look at avoiding heart attacks, maybe you can avoid somebody from having an M.I. and get them to live to 110, but if what they have to do makes them miserable for the next 30 years, you've achieved the stated outcome, but that's not really in synchrony with what the patient desires. Then there's the whole issue of the patient, the family, society – it gets very complex." FP06

"I listen to my patients and I tend to not push them too much, because they're just going to walk out of there and not be compliant. So I think I have to be realistic as to what I expect that they're going to follow when they leave the office. I guess I try to put it in some context that is going to be meaningful to them in that situation, and paint a picture of both sides of what would happen if they followed the evidence and what would happen if they didn't. I try to sometimes let the patient make the decision of which way they'd like to go – obviously with what I feel would be the most appropriate treatment, but in the end it has to be their decision."FP09

"Sometimes you actually get into arguments with patients, and that's stressful. Most of the time I don't give in to the patient. I try to explain it and either they come on side and sort of agree with me or they totally disagree and they probably go and seek care elsewhere, which happens sometimes with the bigger conflicts." FP11