A rapid review service for general practitioners’  - what questions do GPs ask?

 Jill Walton*, Graham Henderson*, Anne Hollings**, Ross Lawrenson*


Jill Walton, Clinical Effectiveness Co-ordinator

Graham Henderson, Consultant in Public Health Medicine

Ross Lawrenson, Consultant in Public Health Medicine

Correspondence to Jill Walton please:Email Jill Walton



Objective. To review the types of questions asked by general practitioners in unobserved routine patient consultations.


Design. A descriptive study of prospectively collected data.


Setting. East Surrey Health Authority area, England.


Subjects. General practitioners.


Results. Between October 1996 and March 2000, 500 questions were received by a dedicated evidence-based information service from 139 different practitioners. 26.6% of questions were specifically related to women, 13.2% to children and 3% to men. Questions about women’s health were mainly about pregnancy (particularly drug safety), hormone replacement therapy, contraception, breast cancer and cervical screening. The most common questions relating to children were about vaccination, asthma and otitis media. For men’s health, the most common question area was prostate cancer. The questions were grouped pragmatically into 14 categories that describe the type of questions asked. The largest categories covered drug treatments for specific diseases and other prescribing issues. Further significant clinical categories covered disease management, epidemiology or aetiology, general information or overview requests, risks and associations not related to drugs, differential diagnosis, alternative or complementary therapies and screening tests.


Conclusions.  General practitioners generate a very wide range of clinical questions during the course of everyday consultations. These questions can be answered rapidly by a small dedicated team who have search and appraisal skills. The majority of questions were about drug treatment for specific conditions, supporting the need for evidence-based information about therapies to be easily available to general practitioners. Most questions as asked are not framed in a way that lends itself to a classical evidence-based medicine approach, but they can be categorised into 14 broad types. Analysis of the cumulative database of questions can identify those clinical areas where knowledge is felt to be lacking and where continuing medical education can be directed.



The information needed by general practitioners (GPs) to be able to provide up to date evidence-based care for their patients is vast and increasing daily. In 1996, Richard Smith estimated that the body of medical knowledge increases fourfold during a doctor’s lifetime [1].  Access to this knowledge base in general has also improved dramatically in recent years, since its availability in electronic format means that sources of information can be rapidly retrieved using a desk top computer.  However, most general practitioners today still have barriers to using this knowledge bank to answer everyday questions concerning patient management in practice.  Apart from the lack of personal access to the range of electronic databases, and the skills to navigate through them, these barriers include managing the information overload [2] and the often rudimentary skills in critical appraisal of scientific literature. The biggest barrier is finding the time to go through the whole process [3][4][5].  Studies have shown that general practitioners are more likely to turn to a text book or to a colleague for an answer than they are to conduct an electronic search of the literature [6][7].


McColl [5] concluded that general practitioners, in their quest to practising evidence-based medicine, would prefer to have improved access to summaries of evidence rather than to be taught the skills of searching and critical appraisal for themselves. Ely et al [7] found that the median time spent in general practice pursuing the answer to a question was I minute, and they reviewed the evidence that busy doctors need bottom-line answers that have been digested into quickly accessible summaries, framed in a way that fits with their own perspective rather than that of researchers.


In order to try to meet these information needs locally, East Surrey Health Authority has been supporting a project initiated by local general practitioners called Merlin GP Information. The aim is to provide general practitioners with evidence-based answers to day-to-day queries that arise during consultations. The service is primarily aimed at answering clinical questions, but in order to encourage question-asking behaviour in general, the service also offers to respond to more general questions about clinical practice. We do not restrict the answering service to any particular type of question, nor do we restrict the format in which questions are framed.  This project has now been running for over three years and we decided to review the types of questions asked by general practitioners, and to gauge their satisfaction with the service.



How the service works

All practices within the health authority area were supplied with a pad on which general practitioners could write down their clinical questions as they arose during consultations. The service was promoted by the Medical Advisory Audit Group lead for the area (AH), primarily to general practitioners, although other primary health care team members have occasionally sent in questions. The questions are faxed or telephoned to the local GP Link Office in Epsom and logged in a database. A general practitioner and clinical manager reads all the questions and will return to the questioner for clarification if needed. The questions are then sent on to the health authority to a consultant in public health medicine who re-frames the question if necessary in order to focus the searches appropriately. Questions that cannot be answered immediately from medical textbooks, the British National Formulary, or other at-hand sources are passed on to a public health information specialist for a structured literature search. Complex queries about drug therapy or interactions are answered by the Health Authority’s pharmaceutical adviser, who may refer to the Regional Drug Advisory Service.


The search strategy always looks for evidence that is classifiable according to the standard evidence hierarchy used in evidence-based medicine [8], for example, a systematic review of randomised controlled trials would rate more highly than an observational study, which would rate more highly than a case series. Most searches begin with the Cochrane Library, then work through the other collections of research that has been subject to secondary review by looking at the web sites for the main evaluation centres in the UK and abroad (full list available on request). The TRIP database, which provides a ‘one-stop shop’ to all the major information databases is also searched [9]. Most of the Merlin questions require a search on Medline or EMBASE databases.  The British Medical Journal and Lancet on-line sites are also searched, since occasionally the question relates to an article seen a few weeks or months ago in these journals. The aim of the information specialist is to reduce the volume of retrieved material down to the most pertinent and scientifically robust references – usually between 5 and 10 articles - to pass back to the consultant for appraisal. If nothing at all is found, a text search on the world wide web using an engine such as Alltheweb or Google is attempted. This has proved useful from time to time in the cases of obscure or rare disorders.


The consultant appraises the abstracts and papers and formulates a brief answer in one or two paragraphs, with the key references as footnotes should the reader wish to pursue the answer in more detail. The response is reviewed by the general practitioner manager on the Merlin team before being sent back to the enquirer. A database of the anonymised questions and answers is kept at the GP Link Office in electronic format so that they can be published on the local internet or the web in the future.

Analysis of the questions

Between October 1996 and March 2000, 500 questions were logged and answers provided. We tried to analyse the question bank using an evidence-based medicine framework, with the questions classified into a question type, a population of interest, an intervention or exposure of interest and an outcome. However, few of the questions were constructed in a way that lent itself to such classification. We therefore used a different taxonomy in an attempt to categorise the questions into a framework more relevant to the questioners’ perspective in primary care. Because the breadth of the questions was so varied, this took a very pragmatic approach, a compromise between having an extensive basket of categories and wanting to draw broad conclusions for the purpose of highlighting areas of information gaps. The taxonomy placed all 500 questions into one of 14 categories. The questions were categorised by two of the authors independently, using agreed rules to distinguish between the 14 categories where possible overlap existed, and any differences were resolved by discussion.


Evaluation of the service

Each Merlin answer is returned to the questioner with a simple evaluation form and a request to send it back completed to the GP Link Office. The form asks for a view on the quality and speed of the answer and whether clinical practice is likely to change as a result. Information from these forms was summarised.



There are 65 practices in East Surrey and 225 general practitioners serving a population of 419,000 patients. Questions were received from 48 different practices and from 139 different enquirers. Of the 500 questions, 480 (96%) were asked by general practitioners, and the remaining 20 mainly by practice nurses and health visitors. Of the 126 different doctors asking questions, 6 asked 10 questions or more, 22 asked 5-9 questions, 53 asked 2-4 and 58 asked a single question during the time frame.


Considering specific populations, 66 (13.2%) questions were specifically related to children, 15 (3%) to men, and 133 (26.6%) to women. The questions about women’s health were mainly about pregnancy (41), hormone replacement therapy (21), contraception (20), breast cancer (12) and cervical screening (12). Common enquiries relating to pregnancy women were about the safety of drugs during pregnancy. The most common questions relating to children were about vaccination, asthma and otitis media. For men’s health, the most common question area was prostate cancer.


Table 1 shows the numbers of questions in each of the 14 categories. Three examples of questions under each category are given in Box 1.  Although whole ranges of interventions were mentioned including surgery, physiotherapy and complementary therapies, the most commonly asked questions were about drug treatment, either about their effectiveness for specific conditions (category 1) or questions about the drug itself – toxicity, contraindications, interactions or dosage (category 2). The interventions in category 1 for specific conditions referred to drug therapy (89%) and surgery or other interventions (11%). Enquiries about drugs covered 29% of all the questions asked.


The next biggest category was about disease management where no specific therapy was mentioned (category 3), covering management regimes, referral protocols, monitoring, lifestyle advice, etc. Category 4 included questions on the genetic susceptibility to certain diseases, cause, incidence and prognosis. There were 32 questions about alternative or complementary therapies, 15 of which were about specific dietary supplements. Enquiries about screening tests fell into two categories – tests for those with and without current symptoms or disease. Together, these categories comprised 8.6% of the total question bank. Screening questions

addressed some common areas – cancers, diabetes, allergies (especially food and nut allergies), and circulatory diseases.


Fifty-seven evaluation forms were returned during the time frame – a response rate of 11%.  The forms were from 34 different respondents, about a quarter of all the enquirers in total. All but four of the evaluation forms were from general practitioners. The analysis showed a general overall satisfaction with the service (Table 2).


The most recent statistics on a consecutive batch of 204 Merlin questions answered in 1999 show that an average of six questions were answered per week, with a median turnaround time of 8.5 days. The Merlin team is engaged in the enquiry service for only about one day of the working week.



The service provided by Merlin GP Information in the last four years has been used by 56% of the general practitioners and nearly three-quarters of the practices in the district. The majority of questions are about treatment, and support the need for evidence-based information about therapies to be easily available to general practitioners. There were very few questions on economic aspects of management (category 13). This is interesting in that one of the criticisms of evidence-based medicine was that it would be used to manage costs rather than improve other areas of clinical practice [10]. Many of the questions relate to specific patient groups, particularly children and women (including pregnant and peri- or post-menopausal women). Very few questions were asked about the specific health problems of men. 


According to morbidity surveys in general practice, many more patients consult for respiratory diseases than any other type of disorder [11].  We had only 17 questions (3.4%) that related to the management of respiratory complaints. Presumably, general practitioners are comfortable managing respiratory complaints, and it is in other clinical areas that they need further information. The type of questions may to some extent reflect the health and socioecomonic make up of the local district – East Surrey has very good health and mortality indicators, and the socioeconomic indicators are at the most affluent end of the spectrum. Patient access to the internet through home and work has also influenced the type of question about which general practitioners are seeking robust evidence-based answers.


Few of the general practitioners in East Surrey have received training in the practice of evidence-based medicine. Consequently the questions are often poorly structured and outcomes were only specified in about a third of cases. The emphasis to date has been on encouraging the asking of questions per se. In the future we hope to

encourage a more structured approach to framing the management question being faced, to allow the people providing the service to narrow their search more closely to the answer needed.


The strengths of the Merlin GP Information service are felt to lie in good team work between the appraiser and the searcher, who puts a quality filter on the studies forwarded, and in the rapid transfer of information electronically. The answers provided are written in clear and concise language, from a clinical rather than an academic research perspective, to meet the needs of the busy practitioner. The user-friendliness of the answers was reflected in the satisfaction scores in the evaluation (table 2).


A particular strength of this study is that, unlike previously published work, it analyses questions that arose in unobserved everyday clinical settings, where practitioners were under no pressure to either generate or suppress questions. The anonymity of the service means that general practitioners feel comfortable in asking for information in areas where their knowledge is not up-to-date, and through a local intranet and paper answers others can share the same knowledge. Analysis of the cumulative database of questions can identify those clinical areas where knowledge is felt to be lacking and where repeat questions occur, for example hormone replacement therapy, oral contraception, food allergies. These areas can then be targeted for joint training or continuing medical education. The ‘hot topic’ list can also be used to inform other national evidence evaluation agencies of the areas in which general practitioners need up-to-date effectiveness information.


A limitation of the analysis lies in the possible ambiguity of question categorisation, resulting from the way in which questions are asked and framed. A few enquiries comprised two or three discrete questions rolled into in one; in these cases we categorised on the basis of the main perceived information need and the answer that had been given. We put questions about risk and associations other than those related to drugs in a separate category (category 6). There was occasionally a blurred boundary between this category and the epidemiology/aetiology category. For example, questions about risk factors for a disease were categorised in the latter (category 4), while the risks of certain interventions (like having breast implants, eating liquorice, skiing while pregnant) were put into category 6.


The evaluation to date has been rather simplistic, and will suffer from the biases inherent in a satisfaction survey that relies on postal returns. For example it is not possible to answer a question if there is no evidence in the literature to provide the answer. Those who replied mostly felt that the information supplied was of good or adequate quality. A key issue is whether the answering service makes a difference to patient outcome.  About 32% of doctors suggested that the answers would change greatly the way they advised or treated patients, while a further 54% felt that their practice would be changed to some extent. Further resources would be needed to track questions through the system to see what changes in practice had in fact occurred. The Merlin service provides an experiential learning opportunity that is both self-initiated and relevant, and has immediate practical application.


There is a large investment nationally in the secondary appraisal of research studies, with several agencies conducting similar types of assessments over the last few years (e.g. Cochrane, NHS Centre for Reviews and Dissemination, the Health Technology Assessment  programme) . However the questions that general practitioners face every day in their surgeries are seldom those being addressed by these evaluation teams and the answering time frame is far too long. Thus Merlin provides quick, short and easily comprehensible answers to pertinent questions. Currently each question takes approximately 4 hours to search for the evidence, retrieve the abstracts, critically appraise them and formulate a response. These are by necessity “rapid review” responses and must be seen in this light. Answers are dated for the record, but not updated unless the question is asked again. 


Similar schemes to the Merlin GP Information project are being piloted elsewhere in the country and there is currently a group of people meeting to discuss these issues and potential solutions under the umbrella organisation NOISE (the National Organisation for Information Support for Effectiveness). This group is attempting to share methodologies, develop quality standards, and share the answers to frequently asked questions. There may be economies of scale to be made in providing such services region-wide.



1)       Smith R. What clinical information do doctors need? BMJ 1996;313:1062-1068.


2)       Noone J, Warren J, Brittain M. Information overload: opportunities and challenges for the GP's desktop. Medinfo 1998;9(Pt 2):1287-91.

3)       Tomlin Z. Humphrey C, Rogers S. General practitioners' perceptions of effective health care. BMJ 1999;318:1532-5.

4)       Fahey T. Applying the results of clinical trials to patients to general practice: perceived problems, strengths, assumptions, and challenges for the future. British Journal of General Practice 1998;48(429):1173-8.

5)      McColl A, Smith H, White P, Field J. General practitioners’ perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998;316:361-365.

6)       Barrie AR, Ward AM. Questioning behaviour in general practice: a pragmatic study. BMJ 1997;315;1512-1517.

7)       Ely JW, Osheroff JA, Ebell MH, Bergus GR, Levy BT, Chambliss ML, Evans ER. BMJ 1999;319:358-361.

8)       Centre for Evidence–Based Medicine (

9)       The TRIP data can be found at http://www.ceres.ac.uk/trip/.

10)   Grahame-Smith D. Evidence based medicine: Socratic dissent. BMJ 1995; 310: 1126-7

11)   McCormick A, Fleming D, Charlton J. Morbidity Statistics from General Practice. Fourth National Study, 1991 -1992. HMSO London 1995



Table 1.  Categorisation of questions asked by general practitioners


Type of question


Per cent


Drugs/treatments for specific conditions





Drug dosage/toxicity/interactions





Disease management










General information/overview





Risks/associations (non-drugs)





Differential diagnosis





Alternative therapies










Screening/testing asymptomatic people





Screening/testing symptomatic people















Evidence base for time-honoured practices











Box 1. Examples of questions (as asked) in each category

1.  Drugs/treatments for specific conditions

§         What is the evidence for the use of progesterone injections in the first trimester in a woman who has recurrent miscarriages?

§         Why do people get prickly heat and what is the correct treatment hierarchy: anti-histamines, steroids or paludrin?

§         Should patients over 75 years of age be offered secondary prevention with a statin if their cholesterol is over 5, and their LDC over 3?  What is the evidence in favour of this?

2.  Drug dosage/toxicity/interactions

§         What is the interaction between Adalat (nifedipine) and grapefruit?

§         When prescribing GTN tablets the computer gives an option between 500 and 300 microgram doses.  Which one should I use for standard angina?

§         Is there any contraindication to taking HRT with varicose veins?

3.  Disease management

§         What is the correct management for a ruptured biceps muscle?

§         How do you treat erythrasma, and how effective is the treatment?

§         Polycystic ovary syndrome - what is the recommendation on long-term follow-up?

4.  Epidemiology/aetiology

§         What are the odds of a child inheriting vitiligo from its mother?

§         What proportion of people with a sore throat are likely to have a bacterial and what proportion a viral throat infection?

§         Is there any evidence that nutritional zinc deficiency is linked to postnatal depression or anorexia nervosa?

 5.  General information/overview

§         Information please on pseudo gouty arthropathy.

§         What is Syndrome X and how do you treat it?

§         How does quinine work pharmacologically on leg cramps?

6.  Risks/associations (non-drug)

§         Is there a relationship between helicobacter infection and rosacea?

§         Is there any link between Down's syndrome and the thyroid status of the mother whilst pregnant?

§         What are the possible side effects or hazards from the regular use of photocopy machines?

7.  Differential diagnosis

§         When an x-ray report says "osteopenia" can you ignore it or does it correlate with osteoporosis? Does this result mean that a bone scan is clinically indicated?

§         Can systemic lupus erythematosus present without a raised ESR?

§         With a single episode of optic neuritis, what is the risk of subsequently developing MS and what are the most likely other causes?

8.  Alternative therapies

§         Is there any evidence for the effectiveness of magnetic therapy?

§         Is there an anti-inflammatory cream made from chilli? (seen recently on TV)

§         Is there any evidence for the use of vitamin E and folic acid in dementia?

9.  Non-clinical/policy

§         How do we get a list of locums available or temporary staff to cover holidays?

§         Where can we get a TENS machine on the NHS for a patient with a Sutton address?

§         Brother and sister would like to know if they have the same father by DNA testing. What is the procedure and the cost?

10.  Screening/testing asymptomatic people

§         Patient aged 59 whose mother died of cancer of the rectum aged 83.  Does she have an increased risk of developing rectal cancer and should she be screened?

§         All new patients here have a "New Patient" medical which includes an examination of urine for albumen and sugar.  Is this a complete waste of time in patients who are below 50, not diabetic and not complaining of anything?

§         Well man age 60 with no symptoms. Is there any screening value in running a PSA test or in doing a digital rectal exam?

11.  Screening/testing symptomatic people

§         Is there a serology test for food allergies, and is it evidence based?

§         38 yr old lady has relapsing multiple sclerosis. Are there any investigations, e.g. MRI scan, that would have predictive value for future relapses?

§         Is there a skin prick test for allergies, particularly asthma?

12.  Vaccinations

§         Is there a vaccine for genital herpes simplex?

§         When giving Hepatitis B vaccine does it make any difference to the immune response where you site the infection (arm, buttock, thigh)?

§         Is the risk of side effects reduced by giving the components of the MMR vaccine separately?

13.  Cost-effectiveness/rationing

§         Is evista more effective at restoring bone mass in known osteoporosis than alendronate?  Which is more cost-effective and which more clinically effective?

§         What is the therapeutic and cost difference between quinine bisulphate and quinine sulphate?

§         In patients with ischaemic heart disease who are allergic to aspirin, is it justifiable to use Clopidogrel as a replacement agent for secondary prevention, bearing in mind that it is far more expensive?

14.  Evidence base for time-honoured practices

§         Is there any evidence that bimanual pelvic examination at the time of cervical smear testing is of any value?

§         What is the validity of clinical breast examination as a screening process?

§         What medical evidence exists, if any, to support the routine 6 week post-natal check?



Table 2. GPs’ evaluation of the Merlin GP Information service (n=57)

Was the information comprehensible?





Did the reply answer your question?




Not at all




Will this information change the way you advise/treat patients?



A little

Not at all




Was the speed of the answer..?


About right

Too slow

(no response)




What were your views on the quality of information received?


Very good







Key messages.

1)      A small dedicated team of people with rapid search and appraisal skills have been providing an evidence-based enquiry answering service for general practitioners in a district health authority area.

2)      Questions about drug therapy for specific conditions and prescribing issues relating to adverse effects and drug interactions were most frequently asked.

3)       Maintaining a database of questions and answers provides an up-to-date resource for general practitioners and can help identify knowledge gaps to guide continuing medical education.



The authors would like to thank Hilary Abbey, GP Link Office Manager, for maintaining the Merlin enquiry database, Dr Ian Clark, Director of Public Health, for informatics management support, Dr Terry Conaty, GP advisor, for IT support and Gul Root, Pharmaceutical Adviser, for certain drug information.  We also thank the East Surrey general practitioners for asking the questions and supplying feedback. Merlin was funded by South Thames Region R & D and East Surrey Health Authority.


Contributors: The Merlin enquiry project was conceived by the East Surrey primary care audit group and the Public Health Department.  AH screens the questions and answers, and promotes the project. GH appraises the evidence and answers the enquiries. JW conducts the literature searches. RL supports the appraisal and answer service. JW and RL conducted the anaylsis. The paper was drafted by JW and RL.  All authors approved the final version. JW and RL are guarantors for the paper.



*Department of Public Health

East Surrey Health Authority,

West Park Road,

Horton Lane,


Surrey   KT19 8PH


**Anne Hollings, General practitioner and GP Link Office Clinical Manager

Shadbolt Park House Surgery,

Salisbury Road

Worcester Park


Surrey. KT4 7BX


Correspondence to Jill Walton please:Email Jill Walton