WHY DO PHYSICIANS NOT MAKE RATIONAL, EVIDENCE-BASED DECISIONS, AND WHAT MIGHT HELP

Overview: Evidence-based medicine (EBM) and medical decision making principles require decisions based on the best evidence from clinical research to maximize individual patients’ benefits and minimize their harms, according to patients’ values. Physicians thus are exhorted to follow ostensibly evidence-based clinical practice guidelines (CPGs). However, physicians only sometimes make decisions according to CPGs. We will discuss traditional theories about why physicians do not adhere to CPGs, including deficient knowledge and cognitive limitations. Since interventions to improve adherence by improving knowledge or addressing cognitive limitations have been largely unsuccesful, we will also explore other possible causes, including influence of extraneous factors, and concerns about the evidence base and construction of CPGs. Finally, we will discuss possible solutions and new research agendas.

Background: Evidence-based medicine (EBM) and medical decision making principles require decisions based on the best evidence from clinical research to maximize individual patients’ benefits and minimize their harms, according to patients’ values. Physicians are exhorted to follow ostensibly evidence-based clinical practice guidelines (CPGs). However, physicians only sometimes make decisions according to CPGs and attempts to improve physicians’ CPG adherence have failed. Traditionally, physicians’ lack of adherence has been attributed to deficient knowledge of the evidence or CPGs, and their human cognitive limitations. Yet interventions to improve physicians’ decisions by increasing awareness or addressing physicians’ cognition have rarely succeeded. In this course, we will consider alternative explanations. On one hand, physicians may respond to extraneous factors, some intentionally designed to influence them. On the other hand, physicians may appropriately resist using CPGs because of legitimate concerns about their evidence base, the processes used to develop them, and the intentions of their developers.

Format Requirements: We plan a seminar format including a mixture of didactic presentations and group discussion. Attendees should have basic knowledge of evidence-based medicine and medical decision making principles.

Description and Objectives: After a brief discussion of the background (see above)...  

Physician Level Problems

We will discuss physician-level reasons that physicians may not make evidence-based decisions or adhere to guidelines.

Ideally, physicians’ decisions should follow EBM principles, so be based on probabilities and utilities of  patient-centered outcomes of decision options determined by best evidence.  Traditional explanations of failure to adhere to CPGs include knowledge deficits, and physicians’ human cognitive limitations, which may degrade probability and utility assessments, and how they are processed to make decisions.  

Also, physicians may be influenced by factors that ought to be extraneous to the decision process, especially the physicians’ own incentives.  Furthermore, these may be perverse, including physician payments, bureaucratic impediments, and conflicts of interest.

Problems with the Evidence Base and Development of CPGs

With an illustrative case presentation, we will discuss why physicians may resist CPGs with  questionable evidence bases, especially when evidence may have been distorted by vested interests.  Distortion may be caused by manipulations of the design, implementation, analysis, and dissemination of clinical studies, and outright suppression of research.  

Furthermore, guideline development may also be distorted, sometimes by vested interests.  Problems include biased selection of clinical evidence, lack of uniform, rigorously critical evidence review, and failure to attend to all relevant patient-centered outcomes and their values to the patients.  

Discussion and Brainstorming

We will propose possible solutions, based on cognitive psychology, and on recent Institute of Medicine reports on conflicts of interest in medicine and development of trustworthy guidelines.  We will finish with a brain-storming session to discuss other solutions and a research agenda.     

Objectives

Understand
- physician level barriers to rational decision making and CPG adherence
- problems with CPGs, including their evidence base and development  processes
- Discuss possible solutions and research agendas