Getting Physicians to Change

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Getting Physicians to Change

Participants at the High Value Practice Academic Alliance (HVPAA) conference hosted by Johns Hopkins University School of Medicine.

Christina DuVernay and Michael Keating

Date: 11/20/2017

As many as 50 percent of antibiotic prescriptions in U.S. hospitals are unnecessary or inappropriate, according to studies cited by the Centers for Disease Control and Prevention. Such overuse exposes patients to potentially dangerous side effects, wastes resources and increases antibiotic resistance — a serious public health threat that accounts for almost 30,000 deaths annually, according to research published in the New England Journal of Medicine.

When strong evidence suggests adopting new practices, why don’t providers do so?

Action bias is partly to blame, says Douglas Hough, associate scientist at the Johns Hopkins University Bloomberg School of Public Health and author of Irrationality in Health Care: What Behavioral Economics Reveals About What We Do and Why (Stanford University Press, 2013). Being told to go home and get rest just isn’t satisfactory — patients want their provider to do something. Doctors, wanting to make patients feel heard and helped, sometimes go ahead and give patients what they want.

Another type of cognitive bias, hyperbolic discounting, also comes into play, says Hough. This is when immediate benefits (satisfied patients) are overvalued and longer-term effects (potentially deadly antibiotic resistance) are undervalued in decision-making.

Hough described these and other cognitive traps in a presentation entitled “Incentives and Physician Behavior Modification” at the inaugural national research and education conference of the HVPAA, which took place Oct. 8-9 in Baltimore. Sponsored by Johns Hopkins University School of Medicine and attended by nearly 200 clinicians, house staff and administrators from some 70 medical centers, the conference focused on improving value in health care by reducing unnecessary and wasteful practices.

Why Change Is So Hard

A physician who’s made a diagnosis of a particular disease and then always prescribes a specific treatment, and sees it work with his patients, says Hough, is going to be hard to persuade. “The most salient evidence is what doctors see with their own patients, in their own work. But they may see a biased sample, they may not actually see final results of their treatments, or there may be other treatments that are better but because they don’t use those treatments, they don’t see results with their own eyes,” he says.

Financial incentives do little good over the long term to change behavior, but applying the principle of least effort can be effective in encouraging higher-value choices. “Make it easier for physicians and patients to choose higher-value tests and treatments, harder to choose lower-value ones,” he says. In the electronic health records systems, for instance, set up defaults to higher-value options. “Practitioners can still choose lower-value tests and treatments, but they have to jump through more hoops to do so,” he explains.

Applying the principle of social norming is effective, too. When physicians perceive that most of their peers are practicing in a new way, they are motivated to do the same themselves.

To learn more about the application of behavioral economics to health care, consult these resources:

Health care debt has become a major contributor to individual bankruptcy and foreclosures in the United States. Both insured and uninsured patients are burdened by medical bills, and health care quality and safety are compromised as patients avoid necessary care.

Addressing these issues is a goal of the High Value Practice Academic Alliance, or HVPAA, a national consortium of more than 80 academic medical centers led by Johns Hopkins Medicine.

“Medical educators have an obligation to prepare the next generation of physicians to deliver high-value care,” said Roy Ziegelstein, vice dean for education at the Johns Hopkins University School of Medicine. “As a leader in both clinical care and medical education, Johns Hopkins must set the standard in this field.”

HVPAA offers “a new model for collaboration, one that transcends cross-institutional competition, geographic constraints and specialties,” said Pamela Johnson, vice chair of quality and safety in radiology at Johns Hopkins University School of Medicine, a co-founder of the HVPAA and organizer of the inaugural conference, which brought together presenters from 50 institutions in the U.S. and Canada. The conference featured some 140 podium and poster presentations about delivering better patient care by reducing unnecessary health care practices, implementing best practice pathways to decrease unwarranted variability in practice and improving discharge transitions to reduce preventable readmissions, among other areas of quality improvement.

HVPAA encourages ongoing collaboration among academic medical centers to identify and spread higher-value health care practices through monthly calls, collaborative publications and multi-institution quality-improvement projects. In these ways, HVPAA members share knowledge about both breakthroughs and setbacks in their efforts to eliminate unnecessary tests, procedures and treatments, and improve patient care.

“We believe that academic medical centers need to step up to the plate, refine practice within their institutions and lead large scale improvement by disseminating results. In doing so, we will demonstrate to patients that medical providers are accountable for delivering the improvements needed in the U.S. health care system,” says Johnson.

Learn more about the HVPAA at hvpaa.org.