Ano is a Justmeans staff writer for health, and an instructional designer for the newly created Master of Health Care Delivery program (mhcds.dartmouth.edu) at Dartmouth College. Ano brings over a decade of evidenced-based health research and writing, and a Masters of Public Health from Dartmouth Medical School to the Justmeans Editorial section. Special interests include health policy, conflict ...
Are Primary Care Docs Ignoring Treatment Guidelines?
A small survey from Germany raises interesting questions about how well primary care physicians follow the latest practice guidelines. Pondering those questions certainly stirs the innovation pot of information technology and services that might inspire better adherence to best medical practice.
German researchers surveyed 437 primary care physicians about their compliance with treatment guidelines for three common chronic conditions: Hypertension, heart failure, and coronary heart disease. They then compared their answers with data about patients that the docs cared for. Only 40% of the physicians were aware of the most recent cardiovascular treatment guidelines, 60% of that group showed "room for improvement."
Here's what's really interesting (maybe): Patients received essentially the same treatment for similar conditions regardless of whether their doc was knowledgeable about current guidelines, somewhat knowledgeable, or essentially clueless of the guidelines.
Why so Lax on Guidelines?
Primary care doctors may be skeptical about new guidelines for several reasons: They value a stable long-term relationship with their patients which they feel could be jeopardized by sudden changes in chronic treatment, and they place high value on intuition and personal experience.
Interestingly enough, while guidelines are supposed to represent the state of the art in medical care, good guidelines will reflect an evaluation of the totality of medical evidence. This means that while they may change slightly over time, they are usually pretty stable in terms of the overall goals and approaches.
The finding that knowledge of guidelines potentially doesn't change treatment seem to imply one of two possibilities: Either doc's who are knowledgable about guidelines don't think that they are important enough to follow them, or all doctors are trained in state-of-the-art care and intuitively provide the recommended care.
In some cases what looks like a dramatic change is the result of poor communication, or misunderstanding. A classic example was the recent change in screening mammography recommendations made by the US Preventive Services Task Force. The USPSTF took a lot of heat when instead of recommending routine screening mammography for women aged 40-49 they endorsed informed patient choice and recommended that a women decide about when to begin routine screening after consulting with her doctor, and considering her own personal risk factors, values, and preferences. Instead of understanding this nuance (which actually represents a profound shift towards empowering patients), the media and many doctors and specialty societies saw this move as essentially a recommendation against the cancer screenings.
Better Care Through Better Information Management?
So where's the opportunity for improvement? A couple of possibilities come to mind. First, what about engaging patients and consumers in the discussion of new guidelines. Not so we can all be even more obsessed about what's killing us, but so that patients can engage in informed discussions with their doctors about any slight shifts in recommendations: "Hey doc, should I stop taking Pill X since they are now saying it should only be taken for short periods of time and not indefinitely?" This of course requires better communication of recommendations to the general public (as well as doctors).
Then there are myriad opportunities, many being exercised right now, for finding ways of keeping doctors up to date with the latest guidelines, and teaching them how to evaluate medical evidence to better understand the risks and benefits of drugs and other treatments. Believe it or not that is not part of the standard training that medical schools provide (at least not in the US). As a result many docs get just as confused as their patients between such important concepts as relative and absolute risks of health states or treatments.
We are all bombarded with information, clinicians more so. Are there ways of using short, Twitter-like bursts of information to remind and educate about complex clinical matters?
Are there multimedia approaches that engage more of our neurons to more effectively cement best practice into the clinicians neo cortex?
Opportunities for integrated, continuous medical education that is actually meaningful, consumable across multiple devices: Listening to my ipod on the commute to work, viewing it on my iPad in the airport, reading it on my Kindle during lunch.
Games? Simulations that allow you to watch what happens to a patient with a certain disease state when you change treatment and fast-forward twenty years?
Tying in financial costs so cost to patient, provider and payer can be added to the decision rubric?
Photo credit: The author