Gabbay John, le May Andrée
Wessex Institute for Health Research and Development, Community Clinical Sciences, University of Southampton, Southampton SO16 7PX.
BMJ. 2004 Oct 30;329(7473):1013. doi: 10.1136/bmj.329.7473.1013.
To explore in depth how primary care clinicians (general practitioners and practice nurses) derive their individual and collective healthcare decisions.
Ethnographic study using standard methods (non-participant observation, semistructured interviews, and documentary review) over two years to collect data, which were analysed thematically.
Two general practices, one in the south of England and the other in the north of England.
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.
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."
These findings highlight the potential advantage of exploiting existing formal and informal networking as a key to conveying evidence to clinicians.
深入探究基层医疗临床医生（全科医生和执业护士）如何做出个人及集体的医疗决策。
采用标准方法（非参与式观察、半结构化访谈和文献回顾）进行为期两年的人种学研究以收集数据，并进行主题分析。
两家全科诊所，一家位于英格兰南部，另一家位于英格兰北部。
一家诊所的九名医生、三名护士、一名采血技师及相关医务人员提供了初始数据；在第二家诊所与全科医生一起检验了所形成的模式的可转移性。
临床医生很少直接获取和使用来自研究或其他来源的明确证据，而是依赖“思维线索”——共同强化、内在化的隐性指南。这些指南通过简短阅读获得信息，但主要来自他们自己和同事的经验、他们彼此之间以及与意见领袖、患者和医药代表的互动，以及其他大量隐性知识来源。在组织要求和限制的调节下，思维线索通常通过流动的“实践社区”中的一系列非正式互动，与各种关键行为者反复协商，从而产生社会建构的“实践中的知识”。
这些发现凸显了利用现有正式和非正式网络作为向临床医生传递证据的关键的潜在优势。
