1. Introduction
Evidence-based medicine (EBM) is considered to be the careful and meticulous use of up-to-date evidence in the decision-making process regarding individual patient care, whereas evidence-based practice (EBP) integrates individual clinical expertise with the best available clinical evidence obtained from systematic research [
1]. Since the term officially appeared for the first time in 1992 [
1,
2], EBM has been the focal point of medicine from both academic and professional perspectives, including EBP [
3], evidence-based nursing [
4], evidence-based health [
5], evidence-based health policy [
6], in research methods [
7,
8], in medical education and training [
9,
10], and during internship/residency [
11]. The importance of EBM has been widely accepted by physicians such as physical therapists, pediatricians, dentists, and orthodontists. British and German surgeons rated EBM, on a scale from 1 to 10, as very important for daily clinical decision making (7.3), patients (7.8), and for the national health system (7.8) [
12]. Moreover, Canadian family physicians embraced the facilitation of EBM in family practices and some physicians alluded to its significance in their daily implementation of EBM [
13]. However, there is a great discrepancy between research evidence and the introduction of this evidence into routine clinical practice due to many factors, ranging from the quality of the evidence, health professionals, patients, and health institutions to healthcare systems [
14,
15]. Moreover, developing countries encounter more difficulties and challenges related to EBM implementation and practice [
16].
The official introduction of EBM into China can be traced back to the year 1996, when The Chinese Cochrane Center (The Center) was established. The Center was approved by China’s former Health Ministry in 1997 and became the 14
th center of the International Cochrane Collaboration in 1999. EBM then spread rapidly across China through the introduction of Clinical Epidemiology and EBM as compulsory curricula in medical universities, as well as through the launch of academic journals such as the
Chinese Journal of Evidence-Based Medicine (2001),the
Journal of Evidence-Based Medicine (2001), the
Chinese Journal of Evidence-Based Pediatrics (2006), the
Chinese Journal of Evidence-Based Cardiovascular Medicine (2008), and through the establishment of professional institutions and academic organizations, such as the
Chinese Medical Doctors Association’s Evidence-Based Medicine Committee (2003) and the
Ministry of Education’s Virtual Research Center of Evidence-based Medicine (2004) [
17,
18].
Although an increasing number of empirical studies on physicians’ knowledge, perception, attitude, competency, and practice of EBM in clinical practice settings have been witnessed in recent years, the relationship between knowledge/attitude and behavior has not been fully explored. Most empirical studies have been conducted in developed countries and few studies have been carried out in developing countries; additionally, very little English literature focuses on Chinese physicians [
19]. In this study, we investigated physicians’ knowledge of, and attitudes towards EBM and their EBP skills and competency, as well as the influencing factors and barriers towards EBP among Chinese clinical physicians.
2. Materials and Methods
This study employed a cross-sectional survey design. The 2013 China Health Statistical Yearbook reported that there were 2,138,836 medical practitioners in China, 1,297,078 of whom were working in hospitals, with 74.1% (961,018) of them in general hospitals and 1.4% (18,379) in TCM-WM (Traditional Chinese Medicine-Western Medicine) hospitals. Based on the above data and a convenience sampling method, three tertiary public hospitals in the city of Wuhan located in Central China were chosen. Hospital A is a general and teaching hospital, Hospital B is a TCM-WM and teaching hospital, and Hospital C is a general and non-teaching hospital. Tertiary public hospitals were chosen because they are the highest-level hospital in China’s medical delivery system. Physicians in these hospitals are more likely to be highly trained and more educated compared to those in secondary and primary hospitals.
The target population was hospital physicians and resident physicians, however, refresher physicians were excluded. Subjects from each hospital were recruited mainly from two departments (Internal Medicine and Surgery).
Hospital administrators and/or the directors of the departments distributed the questionnaires to physicians. Completed questionnaires were recovered by the distributor and checked by the researchers for quality of data collection. The contact telephone number of one of the researchers was included in the cover letter with the questionnaires in case the physicians needed to ask questions about the study. In total, 195 questionnaires were sent out to physicians and 131 completed questionnaires were returned. Demographic data are presented in
Table 1.
2.1. Questionnaire
Based on the definitions of EBM and EBP and relevant references such as McColl (1998) [
20], Heiwe et al. (2011) [
21], and Lammers et al. (2011) [
22], the instrument used in this study was developed. The first section of the questionnaire focused on the participant’s knowledge of, and attitudes towards EBM (6 items). Each item was rated on a four-point scale: ‘0 = none/unimportant’, ‘1 = a little’, ‘2 = moderately’ and ‘3 = very’. The second section was designed to determine the physician’s skills (8 items) and EBP competency (4 items). Using a scale of 0 to 3 (‘0 = none’, ‘1 = some’, ‘2 = moderate’ and ‘3 = a lot’), physicians’ skills were measured by assessing the extent to which respondents knew about professional terminology. EBP competency was comprised of how often the physician applied EBP and the extent to which they considered factors of the decision-making process. This was measured on a four-point scale (‘0 = none/never’, ‘1 = some/rarely’, ‘2 = moderate/sometimes’ and ‘3 = much/often’). The third part of the questionnaire was developed to investigate the physician’s perceived barriers towards EBP implementation.
2.2. Data Analysis
Statistical analyses were performed using IBM, SPSS version 13.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to examine the frequencies of the respondents’ demographics, as well as the physicians’ opinions about EBM and EBP. Univariate and multivariate analyses analyzed the factors influencing physicians’ knowledge of, and attitudes towards EBM, as well as their skills/competency. Linear regression models were used to identify the factors that affected physicians’ attitudes towards EBM and their EBP skills/competence. Logistic regression models were used to identify the factors with a significant effect on physicians’ knowledge of EBM and the implementation of EBP.
4. Discussion
We believe that our investigation is an important effort to assess Chinese clinical physicians’ perception of, and attitudes towards EBM and their behaviors related to EBP, as well as the barriers that impede EBP. Firstly, Chinese physicians in this study possessed moderate levels of EBM knowledge and positive attitudes towards EBM, which is at a similar level to that of their counterparts in Britain, Germany [
12], France and Switzerland [
23].
The establishment of the Chinese Cochrane Center in 1996 was a symbol of the official introduction of EBM into China. After that, a new development model integrating discipline, platform, echelon and popularity [
24] was adopted in view of the fact that Chinese clinical professionals and medical students did not have sufficient training for health technology assessment, epidemiology, and evidence-based medicine. Many Western countries may simply rely on the National Cochrane Center for research, training, and academic activities, however, in China, EBM training and research basically relied on universities [
25], with approval of the National Ministry of Education, which firmly developed EBM discipline, established an EBM platform, and created an EBM echelon. With the initial target of medical students [
13], EBM developed rapidly in universities, and EBM academic organizations and seminars on national, provincial, and municipal levels and EBM academic journals promoted EBM much further.
As expected, here was no strong collision between evidence-based medicine and traditional Chinese medicine or perhaps EBM was only blocked at the individual level of traditional Chinese medicine, owing to the top-down policy path in China. On the contrary, EBM has also burgeoned in the field of traditional Chinese medicine, with the evidence-based Medicine Center of Chinese Traditional Medicine being established [
26] in 2019.
In fact, EBM has been disseminated throughout China during the last two decades. Support from the Chinese government and its relevant departments, such as China’s former Health Ministry, the National Ministry of Education, and the National Natural Science Foundation [
27], may have played a significant role in promoting Chinese physicians’ perception of, and attitudes towards EBM.
However, although physicians had positive attitudes towards EBM, their clinical evidence competence was just at a moderate level, and the actual execution of EBP was not as frequent as expected. This continues to be an abstract field, which, although recognized as important, is not always used in daily clinical practice [
28]. There exists a complex process that can be affected by a mix of factors from physicians’ attitudes to EBP skills to the implementation of EBP.
Our results reveal that physicians’ attitudes towards EBM could be influenced by both an individual factor (interest in scientific research) and an organizational factor (workload). Interest, as an intrinsic motivation and its creation and maintenance is an important tool during learning and instruction [
29]. It can be said that the emergence of physicians’ interest is the cornerstone of their positive attitudes and the first step to conduct EBP. In terms of workload, time is a vital guarantee for EBP and naturally, physicians who own less personal time spend less time training and interpreting evidence [
20].
In addition, we found that physicians’ EBP skills/competence could be influenced by both an individual factor (attitudes) and an organizational factor (hospital’s scientific research requirement). The relationship between attitudes and skills has also been found among registered nurses in China [
30]. At the same time, external research requirements, as a mandatory role, can impel physicians to improve their skills to achieve EBP as well. A previous study about nurses [
31] also demonstrated that a significant factor in promoting EBP was organizational management, for example, support from the hospital to use and conduct research.
This study shows that physicians’ EBP competence affected their implementation of EBP, which is consistent with the findings of a study in the USA [
32] that the development of evidence-based competence provided a key mechanism for the implementation of EBP.
Lastly, time is usually the foremost-cited barrier to the implementation of EBP in many studies [
14,
16,
33,
34], yet, its importance ranked fifth in Chinese samples. The largest barrier in this study was the varying individual differences in diseases. This may well be due to the phenomenon that the overall quality of clinical guidelines in China was generally low, nevertheless, the quantity was large [
35], which casts Chinese physicians’ uncertainty and doubt on the rationality and science of existing evidence. As a result, it is urgent to develop national clinical guidelines of high quality and routinely incorporate them into EBP. Additionally, the results indicate that the second and third barriers were lack of investment from the hospital/department, followed by a lack of patient cooperation. A Swedish study has found that patient participation and patient preferences affected the actual use of evidence in clinical practice [
21]. The premise of EBP is the choice of patients to get treatments that are evidence-based. Our results also imply that it is significant to make a sufficient investment. This may be owing to the extensive impact of EBP on other factors relevant to finding and reviewing evidence, such as EBP resources and training. Previous studies concerning nurses [
36,
37,
38] also found that comparing with barriers to changing practice, those relating to finding and reviewing evidence were more problematic. It is important for healthcare staff to be supported when conducting EBP [
35].
This study has several limitations. First, we used a small convenience sample that focused on one city in China. A total of 32% of physicians did not complete the questionnaire; we could not identify how many of them were a missing sample and how many of them were EBM-minded. Secondly, since Chinese physicians in different types of hospitals (such as tertiary hospital or community health-service centers) in various cities may respond differently, the results were representative of physicians in tertiary hospitals, not representative of physicians in secondary and primary hospitals. Thirdly, we concentrated on individuals and the hospital level. Further studies are needed to explore patients’ perception of, and attitudes towards EBM, which can influence the design of EBM education and the implementation of EBP.