Do Doctors Resist Reform? The Case of Evidence-Based Medical Practice

Many school reformers blame teachers for supporting the status quo and resisting change. In a previous post (April 30, 2011), I argued that, sure, many teachers question classroom-directed policies coming from top officials who last set foot in a classroom when they were high school seniors. And, yes, many teachers point out defects in the innovative program, curriculum, or software  that designers missed. Being a skeptic of a new policy or program, however, is not rejecting change per se since teachers have altered their lessons and activities over the years while introducing new ways of teaching familiar topics. If this is the case for teachers, what about physicians who also have been accused of resisting a major reform introduced two decades ago called evidence-based medical practice.

EVIDENCE-BASED MEDICINE (EBM)

When a doctor sees a patient, takes a history, does a physical examination, and listens to what the patient says, that doctor circles around a possible diagnosis. Using EBM, the doctor would access the clinical literature on his office computer or on a hand-held device to answer questions and reach a diagnosis of what the patient has. The doctor then looks at the guidelines of standard practice for similar cases, critically appraises the evidence, and then decides on the treatment that fits the patient.

One of the designers and promoters of described EBM as follows:

“The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research….”(Sackett_EBP_Spine).

Seems straightforward enough. If you are seeing an asthmatic child, an adult with Type 2 diabetes, a patient experiencing atrial fibrillation for the first time–you access the clinical research database on what are the best treatment guidelines for the particular patient, determine benefits and side effects, costs, and then decide what to do.

DOCTORS RESIST EBM?

Over the past decade, the use of EBM clinical practice guidelines by medical practitioners in the U.S. and Europe has been disappointing across specialties and been estimated at just over 50 percent of doctors who follow guidelines.

One medical director noted: “What makes me change—it’s not scientific, but when I know what my peers are doing.  We meet, we talk, we look at publications”

A general practitioner observed: “If the information is easily available, some people will change.  When sufficient numbers of informed people make changes in their practice then peer pressure will make the rest change”( Giluk & Rynes EBM ch 3-8-11, p. 48)

Although some doctors may find access to and use of clinical guidelines too cumbersome or for other physicians dismissed as “cookbook medicine– Health (London)-2003-Dopson-311-30 ), there are many factors in the profession, workplace and larger environment that account for less use of EBM than advocates may care to admit publicly.

For example, while there is much that separates teachers from doctors (see post for April 24, 2011), as  practitioners in helping professions both doctors and teachers have experienced a loss of autonomy in their daily work (physician autonomy). In the past quarter-century, health management organizations and Medicare have accrued more and more authority to determine payments for diagnosis and treatment; they have adopted evidence-based clinical guidelines to determine payment schedules for fee-for-service doctors in solo and group practices as well as hospitals. What’s more these HMOs use cash incentives to spur doctors to use clinical practice guidelines in improving patient health care.

In public schools, teacher discretion has been squeezed also. Under pressure from state and federal officials for higher student test scores, more districts, particularly in big cities, have centralized their authority in central offices to determine curriculum, school organization, and instructional tools including high-tech devices. District officials have tightened procedures for principals and teachers in gathering and reporting information,  organized incentive plans, and holding practitioners accountable through evaluation and compensation for raising student test scores.  Both professions, then, have felt the pinch of reduced discretion with patients and students.

As with teachers, then, what appear to champions of EBM as individual doctors’ resistance to applying scientific studies to clinical practice is, in reality, doctors raising valid issues  stemming from professional, organizational, and societal factors that go well beyond epithets hurled at doctors (and teachers) of being “stone age obstructionists.”  Both the practice of teaching and medicine combines science and art. Often when reformers accuse practitioners of  being stubborn or supporting the “status quo,” the words mask the continuing tension that exists in both of these helping professions over which aspects of daily practice with individual patients and groups of students are scientific and which are artistic.

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2 responses to “Do Doctors Resist Reform? The Case of Evidence-Based Medical Practice

  1. Pingback: Improving Health Care Decisions By Putting Research Into Practice « Health and Medical News and Resources

  2. This description of doctors’ resistance is incomplete. You are missing the consequences. This article by Pulitzer-Prize winning journalist David Leonhardt helps to fill in the picture. An excerpt:

    During one of our first conversations, Brent James told me a story that you wouldn’t necessarily expect to hear from a doctor. For most of human history, James explained, doctors have done more harm than good. Their treatments consisted of inducing vomiting or diarrhea and, most common of all, bleeding their patients. James, who is the chief quality officer at Intermountain Healthcare, a network of hospitals and clinics in Utah and Idaho that President Obama and others have described as a model for health reform, then rattled off a list of history books that told the fuller story. Sure enough, these books recount that from the time of Hippocrates into the 19th century, medicine made scant progress. “The amount of death and disease would be less,” Jacob Bigelow, a prominent doctor, said in 1835, “if all disease were left to itself.”

    Yet patients continued to go to doctors, and many continued to put great in faith in medicine. They did so in part because they had no good alternative and in part because, as James put it, they wanted a spiritual counselor with whom they could talk about their health. But there was something else, too. There was a strong intuitive logic behind those old treatments; they seemed to be ridding the body of its ills. They made a lot more sense on their face than the abstract theories about germs and viruses that began to appear in the late 19th century.

    So the victory of those theories would require a struggle. The doctors and scientists who tried to overturn centuries of intuitive wisdom were often met with scorn. Hippocrates himself wrote that a physician’s judgment mattered more than any external measurement, and the practice of medicine was long organized accordingly.

    In the end, of course, the theories about germs and viruses won out. They had the advantage of being correct, and doctors — haltingly and skeptically, but eventually — embraced them. “Medicine adopted the scientific method,” James said as we were sitting in his Salt Lake City office, which looks out onto the Utah State Capitol Building and the Wasatch Mountains. “It transformed medicine, and it’s easy to make the case.” Diphtheria, mumps, measles and polio were conquered, and pneumonia and heart attacks became far less deadly. In 1910, life expectancy at birth in the United States was less than 50 years, and it had not risen much for centuries, James noted. Life expectancy today is 78 years.

    http://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html?pagewanted=all

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