Course Level: Intermediate
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.
Background: The principles of evidence-based medicine (EBM) and medical decision making call for physicians to make decisions based on the best available evidence from clinical research that maximize individual patients’ benefits and minimize their harms, according to the patients’ values. Clinical practice guidelines (CPGs) are advocated both to foster such decision making, and to serve as a standard for it. However, evidence suggests that physicians rarely make decisions according to CPGs and many attempts to improve physicians’ decisions have failed. The goals of this course are to review traditionally accepted barriers to rational, evidence-based clinical decision making and adherence to CPGs, consider why these barriers may be insufficient to explain the problems, develop a framework for wider understanding, and discuss better ways to encourage better decision making.
Description and Objectives: Evidence-based medicine (EBM) and medical decision making push physicians to make decisions based on the best evidence from clinical research to maximize patients’ benefits and minimize harms, according to their values. Clinical practice guidelines (CPGs) are advocated to foster such decision making and be a standard for it. However, evidence suggests that physicians rarely make decisions according to CPGs and many attempts to improve physicians’ decisions have failed.
We will discuss “traditional” theories about why physicians fail to make rational decisions and CPG adherence. Such theories may be insufficient, however to explain these problems.
A case study on the treatment of depression, including review of new clinical evidence suggests hypotheses about other barriers, including in some cases, the very CPGs advocated to improve decisions, but which actually may be untrustworthy, and hence should not inspire adherence. We will discuss external influences that may affect physicians’ cognition and impede ideal decision making, including those intentionally designed to further vested interests: manipulations of the design, implementation, analysis, and dissemination of clinical studies, outright suppression of research, manipulation of education, especially involving stealth marketing, deception used in conventional advertising and marketing, and perverse incentives, including physician payment patterns, bureaucratic impediments, and conflicts of interest.
Finally, we will propose some possible solutions, based in part on recent Institute of Medicine reports on conflicts of interest in medicine, and development of trustworthy guidelines.
- “traditional” theories about barriers to rational decisions and follow CPGs
- other barriers arising from external influence
- possible solutions and new research agendas