Changing Physician Practice Behavior

An analytic framework for behavior change

It makes sense that a particular strategy would not succeed in all cases. The reason that clinicians do not adopt new behaviors, or abandon old ones, is often specific to the disease or procedure in question, local practice conditions, and the personal barriers that each physician faces.¹¹ A common solution would not be expected to work. Most physicians undergo stages of change in adopting new behaviors:

1. They must have knowledge (information). They must know about the new data or new practice guidelines that advocate a change in practice behavior. Keeping abreast of this knowledge, with its exponential expansion, is medicine’s great challenge. However, as so many studies have shown, information by itself is not enough.¹²
2. Knowledge must foster a change in attitudes. Clinicians must accept the validity of the evidence and its applicability to their practices and their patients. There must be “buy in” for new practice guidelines and acceptance that the recommendations represent good medical care; have been embraced by peers, local consultants, opinion leaders, or one’s specialty; and are acceptable to patients.
3. Even if physicians know about and accept the behavior, they must have the ability to implement it. Enthusiasm by itself is insufficient if there is a lack of time, resources, staff, training, or equipment. Physicians must have access to eligible patients, and those patients must be able and willing to do their part. (Like clinicians, patients may not comply because of barriers to knowledge, attitudes, ability, and reinforcement.) Finally, constraints imposed by office or clinic operations, practice leadership, information systems, regulations, and insurance coverage can impede change.
4. Like all people, physicians need reinforcement to maintain behaviors. It is human nature to forget, overlook, or lose interest over time. That 36% of physicians do not notify patients of abnormal test results is not because they doubt the importance of that type of communication.¹³ The most committed physician needs reminder systems to remember when to implement guidelines, tracking systems to identify patients who need follow-up, and encouragement from practice leaders, systems of care, and patients that their efforts are appreciated.

Putting the framework to use

This 4-part framework helps to organize the menu of implementation tools that are available to physicians. Some tools focus on providing knowledge, such as conferences, journal articles, practice guidelines, the Cochrane database,¹⁴ and information mastery programs to help clinicians access useful data.¹⁵ Some focus on attitudes, such as local adaptation of guidelines,¹⁶ academic detailing,¹⁷ endorsements by opinion leaders and specialty societies,¹⁸ and feedback from colleagues and patients.¹⁹ Some address ability, such as scheduling and staff changes,²⁰ revised delivery systems,²¹ skill building, teamwork,²² information technology,²³ comprehensive disease²⁴ or total quality²⁵ management, and community support. Some provide reinforcement, such as computerized or manual reminder systems, flow sheets, standing orders, provider incentives, and feedback reports.²⁶

Knowing that, in general, the 4 steps occur in sequence helps clarify why so many methods of changing behavior appear successful in some settings but not in others. An intervention that delivers information is not helpful if clinicians already know the facts but lack ability. If a family practice does poorly in administering polio vaccine, the problem is less likely to be solved by circulating a photocopy of the Advisory Committee on Immunization Practices’s immunization schedule—the physicians already know the guidelines and the importance of vaccination—than by implementing a tracking and reminder system to flag eligible patients, the most effective way to boost immunization rates.²⁷ Conversely, reinforcement tools, such as reminder systems and standing orders, are unlikely to succeed if clinicians are at an earlier stage of change (eg, they are unaware of or question the data). Adding a space for exercise counseling on flow sheets or preventive care forms accomplishes little if physicians are fundamentally resistant because they doubt this type of counseling helps patients. A knowledge intervention is precisely what is needed when physicians withhold warfarin for atrial fibrillation because of the mistaken belief that bleeding complications outweigh benefits.²⁸ Citing an earlier description of this model,²⁹ Cabana and colleagues³⁰ expanded its structure to better organize published evidence on barriers to physician adherence to practice guidelines. In their model, barriers to knowledge include lack of awareness and familiarity with guidelines. Barriers to attitudes include lack of agreement with guidelines, lack of outcome expectancy, lack of self-efficacy, and lack of motivation. Barriers to behavior include factors related to patients (eg, patient expectations), the practice environment (eg, lack of time, resources), and the guidelines themselves (eg, conflicting recommendations). Of the 120 studies on barriers covered in their review, 58% examined only one type of barrier.