The literature on efforts to change clinical behaviors shows that almost all approaches work at least some of the time, but none works all the time.4 That can make this literature difficult to put to practical use by those who seek effective ways to change clinicians’ practices. We believe that our perspective could help explain what may otherwise be puzzling results. If in past studies it were possible to determine reliably the proportion of target clinicians who were seekers, receptives, traditionalists, and pragmatists, we believe most of the findings could be explained by goodness of fit or often the lack of it between the type of clinician and the characteristics of change strategies.
Our framework can similarly help explain the medical field’s enduring bias toward educational interventions, despite ample evidence that education alone seldom changes physicians’ practices.1-4 That bias reflects an implicit assumption that all clinicians are seekers. It is an assumption readily made by the seeker-dominated groups that develop and implement change strategies. Such groups can be expected to favor the kind of purely educational interventions that our framework predicts will succeed only when directed at clinicians who also are seekers and only when there are no major practical obstacles to change. However, because most clinicians are not seekers and because there are often many obstacles to change, purely educational interventions typically fail.
In the example that began our paper, our framework predicts that the educational initiative undertaken by the senior physician would be unnecessary for the seekers in the group, who are likely to already know about b-blockers and use them as recommended. It would be effective for receptive clinicians but not for the pragmatists who may well be in the majority. Our framework predicts that even receptive clinicians will not maintain new prescribing behaviors over the long term without reinforcing facilitative measures, such as the availability of patient handouts about b-blockers and the inclusion of b-blockers on the medical group’s standard hospital discharge sheet for heart patients.
Looking ahead
The theoretical framework we have proposed includes a number of specific hypothesized relationships that are amenable to empiric testing. The psychometric instrument for assessing physician information style must be validated in a variety of practice settings, and we have begun that work. Past attempts to change physician practices, both successful and failed, need to be reviewed against the theory to determine if it accounts for their results. Prospective studies of the acceptability to physicians of various educational and behavioral interventions should show predictable variations by physician information style. Prospective trials of behavioral change interventions guided by assessment of information styles will be the ultimate test for our theory. We have begun to undertake such testing and invite and encourage others to join us in refining this framework, so that changing clinical behaviors can become a much better understood and ultimately more effective endeavor.
Acknowledgments
Based in part on work funded by grant #12549 from the Robert Wood Johnson Foundation and by the sponsorship of the Michigan Consortium for Family Practice Research by the American Academy of Family Physicians.