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September 26, 2018

Why it’s so hard to teach an old doc new tricks

Daily Briefing

    Editor's note: This popular story from the Daily Briefing's archives was republished on Jan. 27, 2020.

    It's hard to teach an old dog new tricks, but for doctors, research suggests it may be harder to unlearn old treatment habits—resulting in overuse that can be harmful to patients and costly for the health care system, Aaron Carroll writes for the New York Times' "The Upshot."

    5 myths physicians believe about patient experience

    Despite a dearth of evidence, doctors continue to overuse certain medical treatments, Carroll notes. "We give antidepressants to children too often. We induce deliveries too early, instead of waiting for labor to kick in naturally, which is associated with developmental issues in children born that way. We get X-rays of ankles looking for injuries we almost never find," Carroll writes.

    In summary, Carroll contends, "Overuse is rampant" in medicine. "And it can harm patients."

    Old habits die hard, study shows

    But part of the problem, Carroll suggests, may be that it's "harder to get [providers] to stop doing things," than it is to get them to adopt new interventions.

    To make his point, he highlights research from 2015 that looked at physicians' response to changing guidelines on blood glucose for ICU patients. 

    At the end of the 20th century, research indicated that keeping ICU patients within a tight range of blood glucose levels reduced mortality rates and adverse events, Carroll explains. Researchers tested the recommendation with a randomized control trial, and findings published in 2001 supported the tighter glycemic control for ICU patients.

    While Carroll writes, "The study wasn't perfect," but the findings still suggested tight glycemic control afforded "a huge benefit," and many experts called for changes in treatment while further research was done."

    Then, a larger study published in 2009 found the opposite: Mortality rates were higher among patients who were in a tight glycemic control group than among the traditional glucose control group. That led to new guidelines, Carroll writes, and physicians were asked to cease tight glycemic control practices.

    But the 2015 study found that doctors had a much harder time stopping the practices than starting them, according to Carroll. After the initial study was published in 2001, "there was a slow but steady increase in" tight glycemic control, Carroll writes. By 2009, the use of tight glycemic control had increased to about 23%, up from 17% in 2001. But from 2009—when the second study was published and guidelines shifted—to 2012, the researchers found no decrease in the use of tight glycemic control practices.

    Why docs are inclined toward overuse—and what might help them

    According to Carroll, patients might factor into physicians' reluctance to abandon medical interventions that are no longer shown to benefit patients. "The public shares some culpability," Carrol writes," as "Americans often seem to prefer more care than less.  

    Nonetheless, Carroll adds, "a lot of it still comes from physicians." He continues, "Professional organizations and others that issue such guidelines also seem better at telling physicians about new practices than about abandoning old ones."

    According to Daniel Niven, the lead author on the 2015 study, physicians often have a difficult time unlearning what they know despite the evidence, "because they work within a system that doesn't adapt well to changing evidence."

    With this challenge in mind, Niven recommends that doctors might wait longer, for better-quality research before adopting new practices. "We need to take a more cautious approach to technology adoption, and learn from mistakes of early adoption of health care technologies based on little or low-quality clinical evidence," he said. "This way we can prevent the need to 'break up' with the practice when the high-quality evidence shows that it is ineffective."

    Carroll writes that overuse is "a significant problem," and that if policymakers are looking "for ways to save money without harming quality in the health care system, reducing overuse seems as if it should be a top option" (Carroll, "The Upshot," New York Times, 9/10).

    5 myths physicians believe about patient experience

    5 myths physicians believe about patient experience

    Excellent patient experience is a critical piece of modern medicine, reflected clearly in outcomes. And more than amenities, clean rooms, or quiet during night, the factors that most inflect patient experience all relate to communication and coordination among the care team—factors that physicians are in a unique position to influence.

    Clinician-patient communication, leadership of the care team, and support and empathy for the patient across the unit are the most important factors for success, and they're all driven by the physician as the "Influencer in Chief."

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