Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care

OBJECTIVE: To explore in depth how primary care clinicians (general practitioners and practice nurses) derive their individual and collective healthcare decisions. DESIGN: Ethnographic study using standard methods (non-participant observation, semistructured interviews, and documentary review) over two years to collect data, which were analysed thematically. SETTING: Two general practices, one in the south of England and the other in the north of England. PARTICIPANTS: Nine doctors, three nurses, one phlebotomist, and associated medical staff in one practice provided the initial data; the emerging model was checked for transferability with general practitioners in the second practice. RESULTS: Clinicians rarely accessed and used explicit evidence from research or other sources directly, but relied on "mindlines"--collectively reinforced, internalised, tacit guidelines. These were informed by brief reading but mainly by their own and their colleagues' experience, their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives, and other sources of largely tacit knowledge. Mediated by organisational demands and constraints, mindlines were iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid "communities of practice," resulting in socially constructed "knowledge in practice." CONCLUSIONS: These findings highlight the potential advantage of exploiting existing formal and informal networking as a key to conveying evidence to clinicians.