Changing Physician-Prescribing Behaviors

There’s a dangerous curve in my neighborhood. A dusty road descends a tree-lined hill and turns sharply. The pavement is broken and rutted on one side so that cars traveling in both directions steer onto a single smooth lane. Collisions have been averted (so far), mainly because few cars travel this section of road. However, an accumulation of near-misses has prompted community members to generate plans to prevent a tragedy.

For several months, safety strategies were confined to reminding drivers to stay within the appropriate lane. Typically, one or two residents would pronounce a “maintain your lane” policy at community meetings, and all present would pledge to strictly obey it or risk provoking the ire of their neighbors. buy kamagra tablets

Meanwhile, the road continued its inexorable erosion, and despite public exhortations and the best intentions, the problem of one neighbor’s vehicle unexpectedly confronting another’s persisted.

Arguments arose to more vociferously broadcast the policy, and proposals to admonish offenders were debated; however, effective corrective actions did not occur until the causes of lane shifting were considered. In acknowledging the unavoidable conditions that lured drivers onto the smooth surface, none of the improvements invoked the initial absolutism that vehicles should never veer from their lane. Instead, a warning sign was placed at the curve’s approach, trees were trimmed, and a convex mirror was positioned so that drivers could see oncoming cars well in advance.

Ultimately, the road should be widened, properly banked, smoothed, and repaved. However, realistically speaking, projected road maintenance budgets are not (and may never be) sufficient to accommodate a definitive correction.

Watching the community’s response to the dangerous road conditions reminded me of attempts to improve physician-prescribing behaviors. In both cases, the potential for miscalculation with tragic consequences is ubiquitous, yet difficult to predict. In the world of medicine, the seemingly simple act of prescribing medications is fraught with blind corners. Even though near-misses expose opportunities to improve safety—for both patients and drivers—complete fixes are often expensive and, therefore, are delayed or, worse, never materialize at all. canadian antibiotics

As with our roads, the initial reaction to a medical near-miss is to blame and shame individuals. In medicine, these impulses are channeled into performance-improvement schemes that invariably include some type of formal education as their centerpiece. Beyond the reaction phase, reforming prescribing behaviors relies heavily on bombarding physicians with written educational materials. These include the formulary substitution letters, specialty society guidelines, and glossy monographs that clutter our mailboxes and elevate our landfills. Although much time, money, and emotion are poured into the production of such well-intended materials, they are, for the most part, ignored.

These kinds of educational attempts are enfeebled by the competing demands for attention that prescribers face; they are disregarded because of the rapid replacement of one intervention with another, and they are tainted by the dubious validity and credibility of some medical and pharmaceutical recommendations. The resulting state of educational impotence is compounded by the lack of applicability of most therapeutic decrees. It is the rare guideline that considers the contextual obstacles of clinical practice—the ruts and the broken pavement—that block implementation and adherence. The good news is that a growing body of validated clinical trials is revealing which interventions improve physician performance and is confirming suspicions about the futility of many traditional educational efforts. The findings from these trials, co-incidentally, converge with the lessons learned from our road modifications.

The first lesson is to focus on an achievable goal. The goal may be that no cars collide on a treacherous curve or that no patient refills a warfarin prescription without a recent clinical evaluation and an International Normalized Ratio measurement. Whatever the objective, setting an achievable benchmark for its attainment has been shown to improve clinically relevant health care outcomes beyond those obtained by common subjective feedback measures. Along with defining goals, a willingness to move beyond physician-exclusive methods of reaching goals expands the pool of effective action in health care. For example, it has been shown that when pharmacists went on rounds with physicians in intensive care units, both the number of medication errors and the cost of patient care were decreased.

The second shared lesson is to elicit change close to the site of service or danger. Coercing safe driving falters when this attempt is made at the neighborhood picnic, and altering prescribing patterns falls short when the topic is taught episodically at distant continuing education courses. Similarly, sporadic lectures from traffic patrollers and expert instructors have little effect on driving behaviors or clinical practice patterns, respectively. However, interactive education, including education outreach (learning in small groups in office-based practice settings), has shown promise in improving prescribing and preventive care.

CLINICIAN’S GUIDE

Guest Commentary of need. Educational enterprises loaded with technology and equipment that vex users or that are beyond the fiscal reach of recipients are unlikely to be adopted. Stepwise introduction of affordable solutions, preferably with the encouragement of local opinion leaders, is more likely to result in desired outcomes. kamagra soft tablets

Finally, performance improvement ventures succeed more often when they are sequential and multifaceted. Like the warning sign, tree trimming, and mirror-placement combination that allows drivers to see around corners and protects my neighbors, the combination of chart prompters, direct order-entry systems, and dedicated clinical support systems builds an effective patient safety net.

Because we will never practice in a time of infinite and instantly available resources but will always be challenged with complexity and an insufficient quantity of useful information, we are left to set pertinent achievable goals and to apply proven and affordable measures to ensure their achievement. Blind corners might not be eliminated, but our vision can be expanded on the road ahead.

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