“You say there’s evidence and these doctors aren’t using it?” asked one of those present. “Why don’t you just fire them?” - Evidence 2010 meeting report -- bmj.com

When Sharon Straus, co-chair of Knowledge Translation Canada, made a presentation to a group of bankers and businessmen, they were bewildered. She explained that well established medical evidence, backed by double blind trials and systematic reviews, was often ignored by doctors.

“You say there’s evidence and these doctors aren’t using it?” asked one of those present. “Why don’t you just fire them?”

Professor Straus was speaking on the second day of Evidence 2010, an international conference at BMA House devoted to understanding why medical practice so often deviates from medical evidence, and what might be done to narrow the gap.

Victor Montori from the Mayo Clinic in Rochester, Minnesota, set the scene by quoting a figure of $290bn (£181.4bn; €208bn), the money estimated by the New England Healthcare Institute to go to waste in the US healthcare system every year as a result of patients not taking medicines as prescribed.

“Only half of clinicians prescribe the right drugs, and half the patients who are prescribed them stop taking them,” he said. “So an intervention with the capacity to cut deaths by 25% only achieves 6%. Patients pay the costs, and suffer the side effects, but don’t get the benefits.”

Dr Montori, a specialist in diabetes, said patients come to his clinic and say they are taking the drugs he prescribed. “I know they’re not, and they know I know they’re not, and I know they know I know they’re not,” he said. “But nobody admits it. We’re both saving face, and creating a gap in the relation between doctor and patient.”

Coercion through threats of dire outcomes for the non-compliant is doubly unethical, he said. “It doesn’t work and highly anxious patients withdraw from care when threatened. They say ‘I’m not going to see my doctor because I’ll be yelled at.’”

His strategy combines better explanations to patients of the benefits they may be missing, and giving them a chance to “choose their own poison” by taking them through the treatment options in a gentle conversation. A patient who has been given a choice is more likely to adhere to the treatment, whatever is chosen, he believes.

He also believes in “minimally disruptive medicine,” trying to devise a strategy that does not leave the patient spending hours each day organising his pills, arranging tests and appointments, and worrying about his disease. For a diabetic patient with multiple co-morbidities, doing this can turn into “a part time job” Dr Montori said.

Language needs to be changed, too. “LDL cholesterol is not a word” he asserted. “I have to talk to my patients about living longer, feeling better, and living unhindered by the complications of the disease. If I can’t do that, I shouldn’t be treating them.”

Paul Glasziou, a GP and former Director of the Centre for Evidence-Based Medicine at Oxford, said that GPs could not hope to be experts in every condition they were likely to meet. Although half a GP’s consultations would be about just 30 common conditions, the other half would cover at least 800 other diseases. “Some we’ve got to learn about when the patient walks through the door,” he admitted.

The evidence for treating all of them existed, but was not always readily accessible. Systematic reviews often omitted a proper description in sufficient detail of the intervention being reviewed. Others prescribed such complex interventions as to be “off the planet.”

He gave examples of a regime to encourage patients to cut salt intake, which worked but was far too elaborate to replicate in general practice, and a positive NICE review of pulmonary rehabilitation for patients with COPD that failed to explain what the treatment consisted of. He found the answer in a YouTube video from King’s College Hospital in London.

YouTube could be a useful aid, he added. One of his partners in his practice in Australia, to which he has now returned, bookmarked a video on the site about the Epley Manoeuvre for dizziness. When faced with a patient, she calls it up. This has the virtue of training the patient in the manoeuvre, and reminding the doctor how it works.

But Professor Straus had the last word, or words. In Canada, the process of translating research into action is called Knowledge Translation but a search of the literature had found 98 different terms for the same process—diffusion, implementation, evidence uptake, research utilisation, translating research into practice, knowledge adoption, and many more. Among 31 funding agencies around the world, there were 33 different definitions of the process—“so some agencies have more than one” she said.

KT Canada is engaged in a comprehensive programme of research into what works, and why. She said that we don’t understand yet how to scale up a system that works in one place and make it work everywhere. “What are the factors that make it happen?” she asked. “We’re looking for a model.”

Whatever it is, sacking patients because their non-compliance is dragging down a doctor’s quality score is a possibility. This is the third commonest reason for patients being forced to seek another doctor in the US, Dr Montori said.

Notes

Cite this as: BMJ 2010;341:c6271

via bmj.com

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