Correspondence

Changing Physicians' Behavior

N Engl J Med 1994; 330:435-436February 10, 1994

Article

To the Editor:

In the recent Sounding Board article by Greco and Eisenberg (Oct. 21 issue),1 an increasingly important mechanism of changing physicians' behavior was not discussed -- that of educating patients in order to change their physicians' behavior. As the authors suggest, educating physicians is less likely to alter their practice if it contradicts patients' preferences. Physicians may indeed oppose any mechanism that they perceive as threatening their sense of competence or autonomy, but such threats may be overcome if the patient is the agent of change.

That the patient can serve as such an agent is increasingly recognized. The national campaigns for cholesterol reduction and awareness of hypertension were addressed to patients as well as physicians. The evolution of direct-to-consumer advertising for pharmaceutical products recognizes the increasing role of the patient in medical decision making. Furthermore, educating the patient before the medical encounter can affect the encounter and subsequently improve health outcomes2.

Managed-care operations may be in a better position to implement patient-centered strategies of changing physicians' practice, especially if they are armed with practice guidelines. Such a shift in control away from the physician may increase patients' satisfaction and minimize the confrontation with threatened physicians. Unfortunately, such a strategy may further erode the therapeutic value of the physician-patient relationship.

James L. Wofford, M.D., M.S.
William P. Moran, M.D., M.S.
Wake Forest University, Winston-Salem, NC 27157-1051

2 References

1. 1

   Greco PJ, Eisenberg JM. Changing physicians' practices. N Engl J Med 1993;329:1271-1274
   Full Text | Web of Science | Medline

2. 2

   Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:Suppl:S110-S127
   CrossRef | Web of Science | Medline

To the Editor:

We believe that access to information is a critical prerequisite to the success of efforts using guidelines. Information systems about patient care are needed to help ensure that the information required to apply guidelines is available at the point of care, can reliably provide an indication of the “best practice,” and can permit instant updating when the consensus on the best practice changes. A computer can sort through a catalogue of guidelines, presenting only those relevant to a particular patient on the basis of the patient's age, sex, type of problems, therapy, and test results. Computers can provide feedback based on orders to influence care before it is given.

Many reports document the successful use of computer-based feedback. Tape et al. showed a significant increase in compliance with three of six health care maintenance procedures when the guidelines were presented as computerized reminders rather than on paper1. After research showed that antibiotics given two hours before surgery were most effective in preventing postoperative infections, a computerized order entered by the pharmacist resulted in 86 percent of antibiotics given before surgery, as compared with 73 percent at base line. When a “rule” was incorporated into the standard computer-based orders, compliance rose to 96 percent2. Other research has documented that physicians respond to all action alerts generated by the computer, and physicians rated alerts about life-threatening situations the most valuable feature of their computer system3. If providers are to change practice, they need access to information about patients and relevant guidelines at the same time that they make decisions about patient care.

Erica Drazen, Sc.D.
Jane Metzger, David Stasior, David Stasior, M.D., M.P.P.
Arthur D. Little, Inc., Cambridge, MA 02140

3 References

1. 1

   Tape TG, Seelig CB, Givner N, Patil K, Wigton RS, Campbell JR. Process in ambulatory care: a controlled clinical trial of computerized records. In: Proceedings of the 12th Annual Symposium on Computer Applications in Medical Care, Washington, D.C., November 6-9, 1988. Washington, D.C.: IEEE Computer Society Press, 1988:749-52.
   

2. 2

   Evans RS. The HELP system: a review of clinical applications in infectious diseases and antibiotic use. MD Comput 1991;8:282-8, 315
   Medline

3. 3

   Gardner RM, Hulse RK, Larsen KG. Assessing the effectiveness of a computerized pharmacy system. In: Proceedings of the 14th Annual Symposium on Computer Applications in Medical Care, Washington, D.C., November 4-7, 1990. Washington, D.C.: IEEE Computer Society Press, 1990:668-72.
   

Author/Editor Response

The authors reply:

To the Editor: We agree that educating patients is a potentially important means of influencing physicians, although it was beyond the scope of our article. The education of patients is appealing partly because it is likely to increase physicians' awareness of their patients' values and preferences. This could result in treatment decisions that are more satisfying to patients. Our chief concern with this approach is the potential for abuse, such as when marketing efforts directed at patients are disguised as educational programs.

Drazen et al. argue that better information systems are needed in order to provide the most relevant and timely feedback. Computers are one mechanism by which this might be achieved, and there is ample evidence that computer-based intervention can improve at least the process of care. One might ask, however, why most physicians and hospitals do not have information systems such as those described by Drazen et al. Is this an example of physicians behaving irrationally -- i.e., ignoring evidence that they should change their practices? Or are there important drawbacks to this form of technology that hinder its adoption, such as price or ease of use?

Peter J. Greco, M.D.
Case Western Reserve University, Cleveland, OH 44109

John M. Eisenberg, M.D.
Georgetown University, Washington, DC 20007

Citing Articles (3)

Citing Articles

1. 1

   Jean-Gabriel Jeannot, Frédy Scherer, Valérie Pittet, Bernard Burnand, John-Paul Vader. (2003) Use of the World Wide Web to Implement Clinical Practice Guidelines: A Feasibility Study. Journal of Medical Internet Research 5:2, e12
   CrossRef

2. 2

   James B. Semmens, Michael M.D. Lawrence–Brown, David R. Fletcher, Ian L. Rouse, C. D'Arcy J. Holman. (1998) THE QUALITY OF SURGICAL CARE PROJECT: A MODEL TO EVALUATE SURGICAL OUTCOMES IN WESTERN AUSTRALIA USING POPULATION-BASED RECORD LINKAGE. ANZ Journal of Surgery 68:6, 397-403
   CrossRef

3. 3

   Richard S. Eisenstaedt. (1997) Modifying physicians' transfusion practice. Transfusion Medicine Reviews 11:1, 27-37
   CrossRef