It is an all too familiar story: A review of medical records at a large primary care group practice reveals that most of the group’s physicians failed to consistently prescribe b-blockers to patients with coronary artery disease for whom they were indicated. At the next general meeting of the group’s physicians, one of the senior members makes a presentation reviewing the evidence on the indications for and benefits of prescribing b-blockers for patients with coronary artery disease. A year later a repeat review of prescribing patterns for b-blockers shows a large initial improvement for some physicians and little or no change for the rest, followed by a gradual regression toward the previous year’s overall pattern. Is this the best we can hope for?
In the past 2 decades we have learned much about changing the clinical behaviors of physicians and other clinicians. Most important, despite the field’s long-standing preference for using educational interventions to induce change in physicians’ practice patterns, we have discovered that education alone seldom leads to lasting change.1-3 Many different change strategies have been found effective some of the time and have their adherents, but none has been found effective all the time.4
We still lack guidance for deciding which strategy is appropriate for a particular situation. That often leaves us at the mercy of conflicting advice.5 To address that gap, we present a new theoretical framework for selecting change strategies. Although we believe that several aspects of this theory are of immediate and practical use, we also recognize that our framework requires empiric testing before it can be put to full use. That work is underway in the Michigan Consortium for Family Practice Research. We present our theoretical framework here to encourage others to join us in testing and refining it.
Context and applicability
Our proposed framework addresses situations in which change is desired because one or more clinicians are not following a diagnostic or therapeutic strategy characterized by both of the following: (1) it has been proved efficacious and effective (examples include prescribing b-blockers to patients with coronary artery disease6 and using the Ottawa ankle rules to determine the need for radiography7,8), and (2) there is a recurring need for it in the clinician’s practice, and any change would affect a substantial number of that clinician’s patients (eg, treating diabetic hypertension in most cardiologists’ or family physicians’ practices).
The four types of clinicians
This framework specifies that selecting the most appropriate change strategy begins with classifying each clinician according to how he or she is most likely to react to new information about the effectiveness of clinical strategies that may affect many of their patients. We distinguish 4 general categories of clinicians: the seeker, the receptive, the traditionalist, and the pragmatist.
The quintessential seeker actively reads professional journals and frequently uses electronic repositories of information. This clinician typically takes an evidence-based perspective on the literature and critically appraises papers. Seekers are as quick to abandon accepted practices when research finds them wanting as they are to adopt new ones when presented with sound evidence in their favor. They are typically not concerned about ending up out of step with locally prevalent practice patterns.Similarly, the prototypical receptive clinician is inclined to change practice in response to new information, as long as it comes from a source that indicates scientific and clinical soundness. In contrast to the seeker, who prefers to critically appraise the scientific literature independently, the receptive clinician relies on the judgments of respected authorities.
Like the receptive clinician, the typical traditionalist clinician relies on authoritative sources for guidance on whether to make changes in clinical practice in response to new information. However, because their learning style is based primarily on training and personal clinical experience, traditionalists focus on the clinical skill, experience, and authority of the advocates for change, in contrast to the receptive clinician’s greater concern with scientific arguments.
The pragmatist is a busy clinician whose concern with new information is its practicality. Any call for the pragmatist to alter some aspect of practice must be placed in the context of the many competing and often conflicting demands made by patients, colleagues, employees, insurers, and hospitals. Although pragmatists may share the seeker’s and the receptive clinician’s basic belief in being guided by what is scientifically and clinically sound or the traditionalist’s belief in clinical experience and authority, they are unlikely to willingly adopt practices if it would risk disrupting patient flow or diminishing patient satisfaction.
It is crucial to understand that these 4 categories represent traits, not states. That is, they are intended to capture characteristic patterns of response to new information. They are not depictions of moment-to-moment behavior: It is not meaningful to say that a physician was a seeker for one case and a traditionalist for another.