We have developed a short psychometric instrument for classifying physicians into our 4 categories. We tested it on 106 family physicians in Iowa and Michigan and found strong support for the theoretical construct on which the instrument is based. A revised 15-item version of the instrument will be administered in a later study to approximately 200 physicians from a range of specialties.
Categorization of change strategies
Eisenberg’s sixfold categorization1,9 was among the first for viewing strategies for changing clinicians’ practices; it included education, feedback, participation, administrative changes, incentives, and penalties. More recent categorizations encompass a similar number of categories, although the labels and the focus they reflect are not necessarily the same.4,5 We have chosen a 2-part categorization that highlights what we see as a critical distinction between commonly used strategies for affecting the knowledge of clinicians and strategies aimed at their behaviors.
Knowledge-oriented strategies are purely educational interventions epitomized by traditional continuing medical education programs. They include all other modalities for diffusing information, from hospital grand rounds to guideline dissemination.
Behavior-oriented interventions are noneducational strategies intended to alter behaviors, typified by incentives and penalties. Within this grouping we further distinguish between facilitative and directive strategies.
Facilitative behavioral strategies are used to remove barriers that stand in the way of a clinician’s adoption of new approaches to care. Too often clinicians are expected to improve care by taking actions that actually require more time and effort. Facilitative strategies can anticipate and remedy such incongruities, primarily by modifying or eliminating administrative procedures and policies likely to impede clinicians’ adherence to desired behaviors.
Directive behavioral strategies are aimed at inducing clinicians to make changes in their practices. While facilitative strategies smooth the way for change to occur, directive strategies are used to make the change actually happen. Predictably, directive strategies revolve around incentives and penalties, though not necessarily monetary ones. An example of a nonmonetary directive strategy is requiring approval from an infectious disease specialist before certain classes of antibiotics can be prescribed.
Matching change strategies to type of clinician
Our main thesis is that changing the practices of clinicians requires both knowledge-oriented and behavior-oriented strategies, but their relative roles and importance will vary for different kinds of clinicians. This is shown in the Table 1, which also illustrates how the types of interventions most commonly mentioned in the literature fit within the larger categories we specified.
Knowledge-oriented interventions are likely to be most effective in changing the practices of prototypical seekers, whose clinical behaviors can be readily influenced whenever they judge information from journal articles and presentations at professional meetings to be scientifically and clinically sound. Even though seekers are likely to make changes in spite of obstacles, virtually all are apt to respond favorably to facilitative strategies that remove obstacles not easily overcome individually, such as long-standing hospital policies or the lack of necessary equipment and other resources. Some directive strategies may also be helpful, though only marginally so, such as higher payments for adhering to evidence-based practices. Directive strategies, however, such as the promulgation of rigid rules, may be especially alienating to this kind of clinician.
Behavior-oriented strategies are the approach of choice for changing the practices of pragmatist clinicians. Chronically pressed by multiple competing demands, it is unlikely they will find time for educational sessions unless motivated by directive strategies. Educational interventions must summarize information efficiently and focus on practical issues and concerns to reach these clinicians, in contrast to the more detailed academic lectures favored by seekers. Most important, however, pragmatists will not adopt the new way of doing things if it increases their already excessive workload or conflicts with patient expectations. Hence the importance, in inducing and sustaining desired practice changes among pragmatists, of facilitative strategies to remove barriers and of directive strategies to provide appropriate incentives and rewards.
It should be noted, however, that even when the same type of intervention is expected to be equally effective for 2 types of clinicians, different strategies are likely to be needed for each. For example, the Table shows that knowledge-oriented strategies are roughly of equal importance in changing the practices of both receptive clinicians and traditionalists. Still, each type of clinician responds best to different specific interventions. The receptive clinician is most likely to heed information from scientific sources, while the traditionalist is best persuaded by information from a respected senior clinician, preferably delivered face-to-face.
Applying the framework
We believe that our perspective on changing clinical practice will be useful for guiding future efforts in the field and for research. In addition, it can help account for some of the inconsistencies and contradictions found within the literature on changing clinical practice and those found between the literature and current efforts to change clinicians’ practice patterns.