We’re spending an inordinate amount of time and effort trying to convince doctors to change the way they practice.
Most recently, for instance, a study came out saying that doctors aren’t following back pain guidelines. Or from a broader perspective, consider the Choosing Wisely campaign, which lists scores of tests and treatments that are ordered too frequently.
Various carrots and sticks have been used to steer physicians to be more adherent to evidence-based guidelines. Pay for performance. And now in the era of accountable care, financial penalties loom for physicians who have poor outcomes.
But will these top-down approaches really work?
I was thinking about this while reading Atul Gawande’s recent opus in the New Yorker. If you haven’t read it, go do so now.
In one segment, he tells a story of improving childbirth conditions in rural India. The situation left much to be desired:
Not long ago, I visited a few community hospitals in north India, where just one-third of mothers received the medication recommended to prevent hemorrhage; less than ten per cent of the newborns were given adequate warming; and only four per cent of birth attendants washed their hands for vaginal examination and delivery. In an average childbirth, clinicians followed only about ten of twenty-nine basic recommended practices.
To change practices, Gawande discusses the BetterBirth project, which gives childcare nurses and attendants “mentors” to provide personalized critiques and instruction.
But progress was slow. After going through one of the classes, not much had been absorbed:
Watching the nurse take a woman through labor and delivery … little of the training had been absorbed. The room had not been disinfected; blood from a previous birth remained in a bucket. When the woman came in—moaning, contractions speeding up—the nurse didn’t check her vital signs. She didn’t wash her hands. She prepared no emergency supplies. After delivery, she checked the newborn’s temperature with her hand, not a thermometer. Instead of warming the baby against the mother’s skin, she handed the newborn to the relatives.
Not encouraging. And when these shortcomings were pointed out by the mentor, the nurse grew defensive.
But after several visits, the relationship between the nurse and mentor warmed, and practices slowly began to change. Gawande caught up to the nurse a few months later, and asked what about the program caused her to improve:
“Why did you listen to her?” I asked. “[The mentor] had only a fraction of your experience.”
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In the beginning, she didn’t, the nurse admitted. “The first day she came, I felt the workload on my head was increasing.” From the second time, however, the nurse began feeling better about the visits. She even began looking forward to them.
“Why?” I asked.
All the nurse could think to say was “She was nice.”
“She was nice?”
“She smiled a lot.”
“That was it?”
“It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.”
That, I think, was the answer.
Policymakers should learn from this. In order to change the way physicians practice, neither top-down penalties or incentives will work.
Admonishing doctors for their behavior, as Ezekiel Emanuel did in a recent JAMA editorial or taking ideology-based shots at them (as the New York Times editorial board routinely does), won’t move the needle.
To change doctors’ behavior, partner with them. Listen to and acknowledge what physicians are concerned about. Medical malpractice and physician burnout, for instance. Propose solutions to these issues, even if it goes against your core politics.
Without offering an olive branch to doctors, it’s unlikely that any of the approaches in the Affordable Care Act will change the way doctors practice.
Just ask the childcare nurse in Gawande’s piece the biggest reason why she changed: “It wasn’t like talking to someone who was trying to find mistakes … It was like talking to a friend.”
And Gawande himself says, “That, I think, was the answer.”
Indeed.
