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 Nilotinib 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. Discussion Although radiologists appreciate the role of EBM in improving patient care, misperceptions of the definition of EBM, a lack of critical appraisal skills and an underappreciation of how EBM could help resolve common tensions within daily practice limited its optimal use. EBM is defined as the integration of best research evidence with clinical expertise and patient values however some participants thought that EBM supplanted clinical expertise and therefore rejected it as being exclusive of clinical wisdom. A common tension cited by many participants was the performance of unnecessary tests, contributing

to excess cost and increased exposure to radiation, however many felt helpless to refuse the request. However, when evidence-based guidelines were available to support appropriate imaging pathways, radiologists felt more confident in negotiating referrals. Some of the barriers to implementing Batimastat EBM we identified have been reported in other areas of medicine and health. Studies conducted in internal medicine and surgery found that confusion about EBM terminology, team dynamics, staff disapproval, and time constraints prevented residents from practising EBM.7 8 In primary care, EBM was perceived by some physicians as devaluing the ‘art’ of medicine and a threat to their professional autonomy, and were concerned about industry influence.5 Another study found that healthcare providers preferred tested, convenient and respected evidence sources including professional societies and expert colleagues.