Health Systems and Physician Behaviour
I was very interested in the article by Lawrence Brass on Health Systems and Physician Behaviour (2003) and the introductory quote, ‘take it from me; it is not easy to change a physician’s behavior’ (Lori-Ann Brass). The author describes acknowledged medication errors and their 243% increase over 15 years (1983 to 1998) in the US increasing from 2876 to 9856 per year. One supposes that these were not the ones picked up as errors by nurses and pharmacists and tragedy avoided.
We learn that medical errors in hospitals kill up to 98,000 people per year, a higher number than motor vehicle accidents. Clearly the quality of health care needs improvement and monitoring and measuring care will lead to that improvement. He goes on to state that physicians are the leaders in focussing on delivery of high quality care to patients and thus have an obligation to lead. However, according to Brass (2003) physicians in the US anyways, seem at least in many cases, unable to take appropriate evidence-based decisions for treatment of patients. The author reflects on the fact that patients with stroke were not treated appropriately half the time, and that there was much variance in treatment. However, he points out that the complex treatment does not involve just one doctor but a whole team, with new technologies and diverse skills pointing out the need for good coordination of the interdisciplinary team. Team members other than physicians, who are knowledgeable about evidence for treatments, may be appropriate leaders to manage care. Quality and cost of treatment must also be discussed and in some cases highly technical care is not the best use of resources.
The author suggests that to change physician behaviour, some methods work well and others so not work at all. Physicians needing continuing medical education (CME) points to continue with licensure may receive all their points from ‘traditional continuing education’ such as conferences or lectures, found to be ineffective for changing behaviour (Brass, 2003), but fun to attend, especially if at a ski resort or on a cruise. Interactive interventions, especially with local opinion leaders, such as the Managing Obstetrical Risk Efficiently Program (MORE OB) team hands-on obstetrical course would be in the ‘effective category.’
Lewis (2007) in his essay on ‘Towards a general theory of indifference to research-based evidence’ discusses the dilemma of setting aside biases and hunches in favour of using evidence-based medicine and guidelines with decision-making for each individual patient. This is juxtaposed with the caveat of the need to ‘use your judgement… an inalienable right, the hallmark of a professional.’ The author proposes another problem; that the practices based on understanding the evidence will provide superior care to practitioners who rely on understanding of basic mechanisms and their own clinical experience. So far there is no evidence to confirm this assumption.
In my years of working in the health sector, in maternity care in various low-resource countries, I have seen extreme variations in practices and wonder why physicians are making the decisions they are. Is it because they do not know the evidence, or because they have other clinical ideas of what works better, or some other reason? I was interested to read that there was a new article on ‘HIFA2015 – Healthcare Information For All by 2015’ list serve on the challenges of translation of the Cochrane reviews into languages other than English, supposedly to reach more policy makers and practitioners. Will physicians, policy makers, researchers and allied health professionals take more seriously the challenge of using evidence in practice? The principal reason for being concerned about physician behaviour change and evidence medicine is its positive impact on health outcomes; therefore we should study the intervention and the KT as part of a package to improve the people’s health.
Brass, L. (2003). Health Systems and Physician Behavior. Seminars in Cerebrovascular Diseases and Stroke Vol. 3 No. 2.
Lewis, S. (2007). Toward a general theory of indifference to research-based evidence. Journal of Health Research Policy. 12(3):166-72
‘MORE OB’ retrieved from http://sogc.org/continuing-medical-education-cme/more-ob/
von Elm E, Ravaud P, MacLehose H, Mbuagbaw L, Garner P, et al. (2013) Translating Cochrane Reviews to Ensure that Healthcare Decision-Making is Informed by High-Quality Research Evidence. PLoS Med 10(9): e1001516. doi:10.1371/journal.pmed.1001516 http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001516