KEY POINTS FOR CLINICIANS
- One size probably does not fit all when bringing physicians new information that might change their practice.
- Physicians differ measurably in what they consider credible sources of information, the weight they assign to practical concerns, and their willingness to diverge from group norms in practice.
- Interventions that bring new knowledge into practice can be tailored to physicians’ perspectives. Further research may show this approach to be more useful to physicians and more likely to succeed than current approaches.
We previously proposed a theoretical framework for selecting the most effective strategies for changing physicians’ practice patterns.1 This framework called for classifying physicians into 4 categories based on how they respond to new information about the effectiveness of clinical practices, then selecting the strategy best suited to each physician’s response style. In this paper we describe the development and validation of a psychometric instrument to classify physicians into the 4 categories. This is one more element in our ongoing effort to answer, rigorously and specifically, basic questions about the adoption of evidence-based practices; for example, how can we increase physicians’ use of proven interventions, such as β-blockers after myocardial infarction or tight blood pressure control for patients with type 2 diabetes? How can we reduce physicians’ use of disproved therapies, such as oral β-agonist tocolytics for preterm labor or antibiotics for viral illnesses?
The literature is rife with examples of singlemode and multimode studies using educational interventions, positive and negative incentives, group and individualized feedback, sanctions, regulations, academic detailing, and patient-demand interventions to bring about changes in physician practice. 2-5 Advocates of these approaches cite published examples of their success in changing clinical practices; in all cases, however, published and unpublished instances of failure exist as well. The lack of a consistent pattern of success or failure has led to a growing recognition that no single strategy will ever be a “magic bullet”5 ; therefore, the selection of practice change strategies must be based on specific situations and settings.6-8 However, it is still not known what characteristics of the setting matter most and which approach will work in a specific setting and situation.
We believe that one key factor in selecting effective strategies is the audience. Businesses learned long ago that market segmentation, in which products are advertised differently to people who have different needs, values, and views, is crucial to success in sales. Similarly, our theoretical framework posits that selecting the most appropriate change strategy requires first classifying clinicians according to how they respond to new information about the effectiveness of clinical strategies. We distinguish 4 classification categories: seekers, receptives, traditionalists, and pragmatists.1
Physician categories and underlying factors
Seekers consider systematically gathered, published data (rather than personal experience or authority) the most reliable source of knowledge. They critically appraise the data themselves and value what they view as correct practice over pragmatic concerns, such as seeing patients quickly and efficiently. Most notably, seekers make evidence-driven practice changes even when the changes are out of step with local medical culture.
Like seekers, receptives are evidence-oriented, but they generally rely on the judgment of respected others for critical appraisal of new information. Receptives are likely to act on information from a scientifically and clinically sound source. Although they do not always hew to local medical culture, receptives generally depart from local practice only when the evidence is sufficiently compelling.
Traditionalists view clinical experience and authority as the most reliable basis for practice, and therefore rely on personal experience and the judgment and teachings of clinical leaders for guidance. The term “traditionalist” is not meant to suggest that the practitioner follows older, more traditional medical practices; rather, it relates to the physician’s traditional view of clinical experience as the ultimate basis of knowledge. The traditionalist may be an early adopter of new technologies if a respected clinical leader suggests them. Traditionalists are not greatly concerned with how their practices fit local medical culture, and are more concerned with practicing correctly than efficiently.
Pragmatists focus on the day-to-day demands of a busy practice. Acutely aware of the many competing claims on their scarce time from patients, colleagues, employees, insurers, and hospitals, pragmatists evaluate calls to change their practice in terms of anticipated impact on time, workload, patient flow, and patient satisfaction rather than scientific validity or congruence with local medical culture. Pragmatists may view either evidence or experience as the most reliable foundation for practice, and may be willing to diverge from local norms when doing so is not disruptive; their primary concern, however, is efficiency.