• John Gabbay and Andrée le May.
• Wessex Institute for Health Research and Development, Community Clinical Sciences, University of Southampton, Southampton SO16 7PX. j.gabbay@soton.ac.uk
• BMJ. 2004 Oct 30; 329 (7473): 1013.

ObjectiveTo explore in depth how primary care clinicians (general practitioners and practice nurses) derive their individual and collective healthcare decisions.DesignEthnographic study using standard methods (non-participant observation, semistructured interviews, and documentary review) over two years to collect data, which were analysed thematically.SettingTwo general practices, one in the south of England and the other in the north of England.ParticipantsNine 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.ResultsClinicians 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."ConclusionsThese findings highlight the potential advantage of exploiting existing formal and informal networking as a key to conveying evidence to clinicians.

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