This "more is better" concept takes root in medical school and is usually firmly ingrained by the time a physician goes into practice, he said. The thrust of medical education is that learning comes by way of making differential diagnoses; but generating those diagnoses requires extensive work-ups with lots of tests, or trying out different therapies to see what works, said Dr. Schroeder. Students and residents are taught that "if you miss something, you’ve failed miserably," he said.
Getting Out of a Practice Rut
As a teacher and a researcher, Dr. Schroeder has observed firsthand how those attitudes carry over into practice. He has taken a special interest in producing research that will help physicians practice less from habit and more from proven experience.
For instance, in 2008, Santa Clara Valley Medical Center decided to adopt recommendations from the U.K. National Institute for Health and Clinical Excellence 2007 clinical guideline that employed an algorithm for doing less imaging of the urinary tract in children who presented with a fever. As at most institutions, urinary tract imaging was routine for all febrile children with urinary tract infections, as a means of ruling out any underlying abnormalities.
But there was no clinical basis for imaging all children, Dr. Schroeder said. He studied the impact of the guideline and found that by letting the 90 pediatricians in the group know that it was acceptable to do less, the rates of imaging went down dramatically, he said. Also, the use of voiding cystourethrography and prophylactic antibiotics went down substantially "without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade vesicoureteral reflux (VUR)," according to his study (Arch Pediatr Adolesc Med. 2011;165:1027-32).
Similarly, at Atrius Health, physician behavior changed in response to some education and data showing that screening colonoscopy was being ordered at intervals that weren’t supported by any evidence, said Dr. Tom Denberg, vice president for quality and patient safety at Harvard Vanguard Physician Associates and Atrius Health. Atrius is a nonprofit alliance of six physician groups in eastern and central Massachusetts.
There was a huge amount of variation in how frequently gastroenterologists were urging patients to come back for repeat colonoscopies – even though there were at least a half-dozen guidelines that should have been informing their recommendations, said Dr. Denberg.
Why weren’t they following the guidelines? In part, because the physicians thought that the colonoscopies would give absolute certainty, and that if patients were brought back more often, nothing would fall through the cracks, such as a flat polyp, which is harder to detect, said Dr. Denberg.
Atrius brought in an expert GI specialist who reviewed the guidelines on screening intervals and also discussed the costs associated with repeat tests. The expert said that screening more often did not prolong life in most cases, or detect flat polyps more often. A malpractice attorney addressed the group, explaining that their litigation risk from not screening – even if a cancer developed – was minimal, especially if the physicians were following the guidelines and documenting procedures and results.
The conversations alleviated physicians’ concerns, and ultimately adherence to the guidelines more than doubled to acceptable levels, Dr. Denberg said.
Global Change Starts Locally
For many physicians – especially those practicing in a fee-for-service environment and in smaller practices that don’t have access to a lot of resources – there might not be much motivation to reduce unnecessary care. In those cases, "we have to appeal to physicians to do the right thing," said Dr. Denberg.
A motivated group of physicians – whether it’s 2 or 20 – who want to reduce inappropriate care can get together and conduct chart reviews to compare how they practice. This exercise illuminates variations in practice and lack of adherence to established guidelines. Reducing variation translates to less waste. Dr. Denberg said that it also gives physicians the leverage they need to dissuade patients from having certain tests or procedures that aren’t backed by clinical evidence, such as MRI for low back pain.
He also talks to primary care physicians about how much administrative time they can save by ordering fewer tests, especially when there is an absence of clear-cut symptoms or any clear clinical rationale. With every set of tests, the physician has to review the results and discuss them with the patient. Often, there are false positives, which require additional tests, or there are abnormal results that aren’t clinically relevant.
"A lot of that is avoidable," said Dr. Denberg.