Validated justification

EBM provided a framework to make clinical decisions based on science, rather than anecdotal data. EBM “added weight, added experience and evidence behind decisions.” And some participants felt reassured when research “validated their own experiences”, and EBM was regarded as an opportunity “to borrow information and techniques from other people who have been using them more.”

Prioritising patient preferences

Shared decision-making was regarded as important though some felt that patient preferences contradicted EBM. For example, they felt unable to deny patients who wanted treatment even when the evidence suggested that the therapeutic intervention would not be cost-effective or beneficial.

Reinforcing protocols

EBM was regarded as useful for developing evidence-based protocols and guidelines. This was particularly relevant in directing decisional pathways for inexperienced referrers. Protocols were seen to protect radiologist's decisions as “you get in trouble for missing something, you don't get in trouble for over-investigating something.”

Ensuring patient safety

Some were convinced that EBM had demonstrable impact on ensuring safe patient care. There was reference to studies assessing safe dosages of gadolinium in patients with renal impairment, reducing the incidence of nephrogenic systemic fibrosis. Participants remarked on the “increasing number of normal examinations which meant they were scanning more people, and that they were not selecting them correctly.” They felt a burden of responsibility—“we definitely do cause the public harm, we just don't know how many [malignancies] is due to us yet” and believed that applying EBM in diagnostic radiology could reduce overexposing patients to unnecessary ionising radiation and risk of malignancies.

Maximising efficiency

Participants felt certain that the financial costs to public hospitals incurred by performing excessive radiological tests and procedures could be minimised by applying EBM. Some suggested that evidence-based referral guidelines may reduce the number of unnecessary diagnostic tests ordered by referrers and improve economic and service efficiency.

Requiring immediacy

Simple and direct access to information was important. Most used Google or PubMed as their primary search engine. Some relied on email updates or review articles to keep up-to-date. Evidence summaries offered information that “had already been critically appraised, filtered out so most of the rubbish wasn't there.” Being unable to access journals due to institutional restrictions “added an extra element of difficulty” however, some participants who had received EBM training felt confident about searching for high-quality scientific research using MEDLINE and the Cochrane Library.

Inadequacy of evidence

Radiological technologies often “progressed before the evidence could come out.” Some observed that diagnostic procedures (eg, CT angiograms for vertebral artery dissection) were used without supporting evidence. In radiological research, some felt that relevant outcomes could not be feasibly measured, for example if it necessitated surgical or autopsy proof. Research in diagnostic imaging was unavailable particularly for rare clinical cases. They felt that, “there's no culture of [radiology] research except in little pockets and enclaves in different institutions few and far between.”

Time constraints

The ‘fast-growing field’ of radiology meant participants felt without capacity to be “a true academic,” engage in research, and “to go through everything we do and find the evidence to prove that that's the best method or way of doing something.” Instead of an appointment-based patient caseload, radiologists had to manage a continuous inflow of patients, which was more difficult to keep manageable particularly if working in a smaller radiology department, or in the private sector. Some reviewed the literature only when required to, for example when preparing for presentations.

Proximity of peer networks

Participants relied on their colleagues to discuss and resolve cases. In larger radiology departments, participants could readily contact experienced colleagues for advice. One participant stated, “My approach to medicine is a very practical approach and based on my experience and the knowledge of others, my skill set is complementary to others so I use their skills.” Interventional radiologists valued practical suggestions from colleagues about procedures and participants attended conferences to learn about new procedures and protocols, then turned to “selected articles on the nuts and bolts, assuming that somebody has looked at the utility of the procedure.”

Grasping information dispersion

The field of radiology was described as broad, “dynamic,” and all-encompassing of different subspecialties which augmented the challenge of keeping up with the literature—“radiologists in most places are generalists, you have to be able to do neurology, gastroenterology, intervention, it's not actually possible to be at the top level of science in all those fields.” They felt “confounded by the plethora of information that you can't filter anymore.” Radiologists practising within a narrow subspecialty felt better able to remain aware of the current literature in their area.

Perceptible applicability

From a practical perspective, some judged the clinical relevance of a research article rather than the methodology. One participant reflected, “I'm not an academic, I'm much more practical, I'm more operational.” They would “look at what they do and the outcomes measures more than analysing the way they get the outcomes.” Research results that were too broad or excluded relevant patient groups made it difficult to extrapolate or assess the transferability of the findings to their own patient population or to an individual patient—“like meta-analysis, you have to spend more energy on trying to pick out tiny fragments of useful data, so most of the time the article was justifying itself and talking about itself, I just want to get to the crux of the matter.”

Preserving the art of medicine

There was anxiety that “if everything gets based on evidence based medicine, we lose the art of radiology.” Participants with more years of experience believed in learning from practice, observing senior colleagues, and developing expert intuition, more so than ‘reading about things’ as EBM could ‘never capture the whole story.’

Technical demands

The technological advances in radiology placed demands on participants to prioritise their technical competence and knowledge of anatomy and pathology. They had to “keep on learning new tricks, as well as refine what they knew before” and study textbooks and ‘didactic’ articles rather than scientific research publications—“What does such a condition look like on ultrasound? You don't need a research article.”

Conceptual obscurity

The perceived complexity of concepts, mainly relating to critical appraisal and statistical analysis, was overwhelming. Many described their judgement about study validity as ‘superficial’ and felt they lacked a framework for critically appraising an article—“we all aspire to practice EBM but we don't necessarily know how to and I think there's a lot of quasi EBM going on.” Some assessed articles based on sample size, participant characteristics, and blinding. Also, some believed a high-level understanding of statistics was required for EBM, perceived to be daunting, “we've come out of it with this monster that most of the radiologists don't know how to cope with, most of us left statistics behind in high school, we don't have this analysis in our brains.”

Reputation-based trust

Participants trusted journals with high impact factors, and articles from reputable institutions with experienced authors. They placed confidence in editorial integrity and expertise to ensure that only high-quality and valid research articles were published.

Demands constant practice

EBM was a skill that required ongoing practice. Participants suggested regular EBM training, and journal clubs to maintain EBM proficiencies, such as conducting critical appraisal.

Suspicion and cynicism

Some were suspicious of authors who might be misusing research to push their own agenda, “People usually decide what they want the reality to be and then harness the appropriate evidence that they want to support it.” For example, in diagnostic cardiac imaging, one participant observed nuclear physicians advocating for nuclear medicine while cardiologists were promoting stress echocardiogram, and both presented compelling arguments supported by research. Contradictory results also perpetuated cynicism of EBM, “I've seen a few cases where different meta-analyses will draw completely different conclusions from the same set of data analysing the same papers.” Some were wary of academic competition, and the ‘politics of journals, and personal egos.’ However, multiple independent studies which demonstrated confirmatory findings, provided reassurance.

Hierarchical conflict

Disempowerment prevented the practice of EBM. Some radiologists felt that referring physicians perceived them as service providers rather than as consultants. They viewed that “referrers don't feel that radiology should be gate keepers.” Being ‘secondary referrals’ most radiologists did not control patient management and lacked clinical information about the patient. Some resigned themselves to ‘defeat’ and ‘dogmatism’ as they continued to perform tests they regarded as unnecessary. At times, there was a palpable tension between keeping referrers satisfied and advocating for the patient's safety and preventing them from being “irradiated just for expediency rather than a clinical indication”. Some tried to ‘battle’ with referrers but withdrew from the “uneven playing field”. More senior participants felt that referrers respected their recommendations.

In certain radiology subspecialties including paediatrics, oncology, and obstetrics, radiologists participated in multidisciplinary meetings and valued the active engagement in patient management where their expert opinion contributed to the broader decision-making. Participants appreciated this ‘cross-pollination’ of information and clinical history.

Prevailing commercial interests

Private radiology centres faced the pressure of “generating revenue to keep the practice going”, which was perceived to nullify any impetus to implement EBM. Some believed that “evidence-based medicine will never work in an item for service based medical culture” and there was “no real incentives for doctors to do the right thing” in referring patients for radiological diagnostics tests. To protect a thriving business, they kept referrers satisfied by fulfilling their radiological requests, even when it was not evidence based.