Teaching an Old Dog New Tricks

T OO often in med ic ine we lack the level of sc ient i f ic evidence requ i red to in fo rm a n d g u i d e c l in ical prac-

tice, forcing us to rely on c l in ica l exper ience , anecdote , and j u d g m e n t . But as Lee a n d col leagues d e m o n s t r a t e in th is issue, ~ p h y s i c i a n s of ten fail to do the r i gh t t h i n g even when s t rong evidence is p rov ided by r igorous , valid, and reliable data. Conf i rming the f indings of several o ther s tudies , Lee et al. d e m o n s t r a t e tha t the use of nomo- g rams to gu ide i n t r avenous h e p a r i n t h e r a p y re su l t s in enhanced safety a n d efficacy. Yet, t h i s p a p e r is the la tes t of s tud ies to d e m o n s t r a t e t ha t m a n y p h y s i c i a n s con-

t inue not to use p rac t ice gu ide l ines , de sp i t e t he i r c l in ical effectiveness a n d w idesp read avai labi l i ty . 2 Why don ' t

phys ic ians use wel l -accepted prac t ice gu ide l i ne s when they are ava i lab le?

Phys ic ians have engaged in extens ive a n d t ed ious d i scus s ions a b o u t w h e t h e r p rac t ice gu ide l ines will un- de rmine the profess ion by m a k i n g it fall p rey to r ig id "cookbook medicine. '" However, m o d e r n sc ience has long coexisted wi th guide l ines . Tex tbooks a n d review ar t ic les are n o t h i n g more t h a n in formal gu ide l i ne s developed by indiv idual au tho r s . Facu l ty t each s t u d e n t s b a s e d on in- tui t ively a n d subject ively der ived gu ide l ine s t h a t a re commi t t ed to m e m o r y r a t h e r t h a n t r a n s l a t e d on paper .

As a result , p h y s i c i a n s comple te t r a i n i n g wi th several vers ions of t eacher ' s "gu ide l ines" a n d are forced to select among them.

Practice guide l ines , cr i t ica l pa thways , a n d c l in ical a lgor i thms are u b i q u i t o u s , hav ing been e m b r a c e d by profess ional socie t ies , federal agencies , hosp i t a l s , man-

aged care g roups , a n d others . The developers of these tools too often cons ide r the i r t a sk to be an a d m i n i s t r a - tive one tha t r equ i r e s only the a c h i e v e m e n t of c o n s e n s u s a r o u n d scient i f ical ly b a s e d evidence. Given the h igh vol- ume a n d vary ing qua l i ty of the p u b l i s h e d l i t e r a tu re a n d the difficulty ach iev ing c o n s e n s u s a m o n g exper t cl ini- cians, the deve lopment of p rac t ice gu ide l i ne s is t ime- c o n s u m i n g and resource- in tens ive . As a resul t , the development of p rac t ice gu ide l ines h a s been overem- phasized.

The same a m o u n t of a t t e n t i o n a n d effort s h o u l d be devoted to i m p l e m e n t i n g p rac t i ce gu ide l ines , i nc lud ing formal, r igorous a s s e s s m e n t of the effect of p rac t ice guidel ines on pa t ien t care and outcomes. Wi thout enough a t t en t ion to i m p l e m e n t a t i o n s t ra tegy , vo lumes of wr i t t en

d o c u m e n t s are p roduced tha t , once d i s t r i b u t e d , s i t in filing cabine ts , s t ack up on phys ic ians" desks , or get

tossed into was tebaske t s . Success fu l i m p l e m e n t a t i o n of pract ice gu ide l ines r equ i r e s a n u n d e r s t a n d i n g of the pr inc ip les of medica l dec i s ion m a k i n g a n d of the psy- chology of medica l innova t ion , all in o rde r to change phys ic ian prac t ice behavior .

Behavior is a compl ica ted p h e n o m e n o n . C h a n g i n g

phys ic ian behav io r is a complex o rgan i za t i ona l endeavor

requ i r ing cons ide rab le a d m i n i s t r a t i v e exper t i se a n d ex- perience. C h a n g i n g p h y s i c i a n behav io r is a func t ion of the deve lopment a n d i m p l e m e n t a t i o n of effective dis- s e m i n a t i o n , c o m p l i a n c e , a n d o u t c o m e - a s s e s s m e n t strategies, inc luding pub l ica t ion in medical j ou rna l s and newslet ters , d i rec t m a i l i n g s to phys i c i ans , a n d d i scus - s ions at medical s ta f f m e e t i n g s a n d c o n t i n u i n g educa- t ion sess ions . The cha l lenge here is to m a k e the infor- mat ion easily access ib le to p h y s i c i a n s a n d o the r t a rge t groups in a user - f r iendly fo rmat via a r e spec ted d i s sem- inat ion vehicle. The l ike l ihood of success fu l ly c h a n g i n g phys ic ian behav io r is i nc reased if the p h y s i c i a n s who

are the target of the gu ide l ines are involved in the i r de- velopment a n d i m p l e m e n t a t i o n . 3 Thus , bo th the mes- sage and the m e s s e n g e r are impor t a n t , as well as the se t t ing in wh ich the message is delivered. 4

S t ra teg ies t ha t e n h a n c e compl i ance inc lude edu- cation, feedback repor t s to c l in ic ians a b o u t t he i r per- formance (often u t i l i z ing peer compar i sons ) , a d m i n i s - trat ive m a n d a t e s , a n d f inancia l incent ives . Each of these in te rvent ions has been d e m o n s t r a t e d to have l imi ted success. E d u c a t i o n is often neces sa ry t h o u g h genera l ly not suff ic ient to change p h y s i c i a n behavior , a A d m i n i s - trat ive and regu la to ry in te rven t ions , whi le of ten suc-

cessftll init ially, f requent ly become b u r d e n s o m e a n d dif- ficult to su s t a in . S t r a t eg ie s u t i l i z ing cl inical o p i n i o n leaders are effective, a l t hough relat ively diff icult to im- plement.5.6 F inanc ia l a n d social incen t ives are effective and relatively easy to i m p l e m e n t a n d s u s t a i n ( a l though 'it often is diff icult to coord ina t e the var ie ty of incen t ives tha t affect a p ro fess ion such as medicine) . Posi t ive in- centives are t h o u g h t to be more effective t h a n nega t ive incentives. 7

However, behav io r of ten is too i n g r a i n e d a n d resis- tan t to be a l te red cons i s t en t ly by any compl iance s t r a t - egy in isolat ion. Ra ther , c h a n g i n g phys i c i an behav io r is most likely to be success fu l when several of these com- p lementa ry m e t h o d s are combined . The focus of mos t efforts to change medica l p rac t ice is a lmos t exclusively on the phys i c i an as the locus of behav io r a n d is d i r ec ted toward improv ing p h y s i c i a n dec i s ion mak ing . Usual ly

inadequa te a t t e n t i o n is devoted to the e n v i r o n m e n t in which the phys i c i an prac t ices , a n d there is u n d e r e m - phas i s on the a d m i n i s t r a t i v e a n d o rgan iza t i on fac tors tha t are needed to c h a n g e the p rac t ice e n v i r o n m e n t . Compl iance s t r a t eg ie s m u s t be a d a p t e d to the local or-

gan iza t ion ' s s t r u c t u r e a n d cul ture . C h a n g i n g envi ron- menta l factors of ten is r equ i r ed to s u s t a i n behav io ra l change, especial ly when mot iva t ion is l ack ing or incen- tives are a m b i g u o u s (as is often the case). 8

Finally, a s t r a t egy m u s t be developed for a s s e s s i n g the impac t of gu ide l ines on cl inical care. Gu ide l ines do

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354 Editorials JGIM

n o t a lways i m p r o v e c l in ica l c a r e a n d m a y c a u s e u n a n -

t i c i pa t ed n e g a t i v e o u t c o m e s , a T h u s , o n g o i n g , t i me l y

m o n i t o r i n g c a n b o t h c o n s o l i d a t e t h e d e s i r e d b e h a v i o r a l

c h a n g e s a n d i d e n t i f y t h e n e e d for r e v i s i o n of t h e g u i d e -

l ine or i t s i m p l e m e n t a t i o n s t r a t e g y .

P r a c t i c e g u i d e l i n e s c a n r e d u c e u n c e r t a i n t y a n d

c h a n g e p h y s i c i a n p r a c t i c e b e h a v i o r , b u t t h e y n e e d to b e

i n t e g r a t e d w i t h o t h e r i n t e r v e n t i o n s to e f fec t s u s t a i n e d

c h a n g e . T h u s , g u i d e l i n e s n e e d to be i n t r o d u c e d in m e d -

ical s choo l s , i n c o r p o r a t e d i n t o t e x t b o o k s , r e i n f o r c e d in

cl inical c l e r k s h i p s , a n d i n c o r p o r a t e d i n t o p r a c t i c e en -

v i r o n m e n t s . In a d d i t i o n , g u i d e l i n e s n e e d to b e s t u d i e d ,

a s s e s s e d , r ev i sed , a n d o p e r a t i o n a l i z e d so t h a t p h y s i -

c i a n s b e c o m e c o m f o r t a b l e w i t h t h e m as i n h e r e n t c o m -

p o n e n t s of c l in ica l care .

M u c h of t h e e f for t d e v o t e d to p r a c t i c e g u i d e l i n e de-

v e l o p m e n t will be w a s t e d if t h e r e is n o t a c o r r e s p o n d i n g

c h a n g e in p r a c t i c e b e h a v i o r . F a i l u r e to r e c o g n i z e t h e

complex i ty of p r a c t i c e g u i d e l i n e i m p l e m e n t a t i o n h a s re-

su l t ed in m a n y false s t a r t s . It is t i m e n o w to b e g i n de-

vo t ing as m u c h c rea t iv i ty , e f for t , a n d r e s o u r c e s to facil-

i t a t i ng g u i d e l i n e i m p l e m e n t a t i o n a s we h a v e d e v o t e d to

gu ide l i ne d e v e l o p m e n t . - - J . SANFORB SCHWARTZ, MD,

Executive Director, Leonard Davis Institute of Health Economics, and Robert D. Eilers Professor of Medicine and Health Management & Economics, University of Pennsylvania, Philadelphia, PA 19104; and DAVID J .

S~rOLKIN, MD, Chief Quality Officer, University of Penn- sylvania Health System, and Assistant Professor of

Medicine, University of Pennsylvania, Philadelphia, PA

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