What to do when evidence contradicts experience
During a recent meeting of the Patient Safety Committee, Chair David Ring, MD, PhD, facilitated a discussion on how physicians can deal with the conflict between evidence and experience. Participating committee members Dwight Burney, MD; Michael Pinzur, MD; Alan Reznik, MD; Andrew Grose, MD; and Michael Marks, MD, shared strategies.
Dr Ring: As physicians, we all have ways of dealing with the limits of modern medicine—habits we fall back on when we face difficult situations. Maybe we order a test, give a shot, or write a prescription for therapy. The things we do to get out of the room. The things we do to avoid upsetting a patient.
The idea that the habits we use to get through the day aren't always in line with what's best for patients is another concept that we need to make more appealing. How do we get surgeons curious about ways to manage those delicate and stressful situations without compromising on integrity?
To illustrate this point, when a placebo-controlled trial that showed that pretending to do surgery, washing out the knee, and actually taking something out were all equivalent, the reaction was not awe, or curiosity, or wonder. It wasn't incredible respect for resiliency and the placebo effect.
Dr. Burney: It was anger.
Dr. Ring: Anger, resentment, and withdrawal. Similarly, 14 placebo–injection-controlled trials of corticosteroid injection for enthesopathy of the extensor carpi radialis brevis (aka tennis elbow) have been conducted. Only four—all early trials with poor methodology—showed a positive effect. Many orthopaedic surgeons still give cortisone injections because they feel they need to do something. It's a habit.
Think of a 55-year-old man with knee pain that is markedly limiting activities that are very important to him. You know the diagnosis is arthritis, but he wants the diagnosis to be a meniscal tear that can be fixed. In his mind, the only way he can continue to be active is to eliminate the knee pain. That's a tricky situation. How do you handle it? What's your habit? Are you curious about, potentially, having a better way to handle a situation where a person has an incurable problem like arthritis, but thinks that a cure is his or her only hope? Are you curious about evidence that might direct you to that better technique?
Dr. Pinzur: Resistance to change is built into our nature. I'll change if you get me good evidence.
We got very comfortable doing arthroscopies on every 55-year-old with progressive knee pain because they all got better for a few weeks. Surgeons are humans. It's not easy for us to value scientific evidence over that first-hand experience. We're not accustomed to thinking of ourselves as fallible. We don't expect to be told we are misinterpreting our everyday experiences.
Dr. Reznik: Even when it's clear that we should change, trying to effect change too quickly may increase resistance. We have to be careful to focus on an area with easy agreement first, and allow it to creep into other areas as it develops. It can be a problem to overreach on the first step.
One of the smartest surgeons I have ever known, the late Dr. Dale Daniel, would say, "There are usually three things required for a smooth surgery—a good, well-prepared facility; a good team; and a well-practiced, good surgical technique." He would follow that with, "To do something new, you can only change one of the three at a time." He understood that changing a practiced procedure without harming the patient takes coordination, effort, and great patience. Altering a treatment style or habit honed over years requires the same type of attention to effect a truly positive change.
Dr. Ring: In other words, it's the difference between "We're coming in with the hospital policy" and "Who wants to try this out and partner with me?"
Dr. Reznik: Yes. That would be one great way to apply this idea to clinical habits.
Dr. Grose: It's similar to shared decision making with patients. We need a way to get feedback that we perceive as nonthreatening. There isn't a doctor in the country who doesn't want to improve the care he or she provides patients.
If someone is watching as a coach to help surgeons reach our goals, I bet many of us would be open to feedback and change. It works in aviation. Pilots feel, "You're not forcing something down my throat. This is, actually, something I want. I want to be better at managing complexity outside of my control and at managing and mitigating the effects of my own small mistakes that pop up." We need to create systems where surgeons crave feedback and are open to adapting to it.
Dr. Ring: What I'm hearing is that we have to make it appealing and compelling for individuals to want to rethink their habits.
Dr. Grose: We have to remember that in being observed and being coached, probably 95 percent of what we're going to get is positive feedback. We need to capture the things people are doing well, so they become more open to addressing the opportunities that are identified.
Dr. Marks: We like to try new tools, toys, and technologies when they come along. When we talk about the process of rethinking a problem, the cognitive aspect of doing something differently, it doesn't go over as well.
Dr. Ring: A colleague noted that when evidence shows a surgery works, it rapidly changes practice. But when evidence shows something doesn't work, the impact is muted and delayed.
Any findings that run against our intuition or against our interests are likely to be slow to take hold, as shown in Tom Lee's article, "Eulogy for a Quality Measure." Despite randomized trials with thousands of people showing that beta blockers were life-saving after a myocardial infarction, the use of beta blockers was slow to take hold. It was counterintuitive. People thought: "You're going to slow the heart down just when it needs more blood?"
Presentation of the data didn't change practice much. Neither did publication. Support from professional societies didn't have much impact. Guidelines didn't do much. Publicly reporting rates of use of beta blockers after myocardial infarction changed practice patterns over the years. Now it's up to 99 percent compliance, so they can put this quality measure to rest and stop reporting it. It took 25 years to change habits in spite of compelling evidence. How do we shorten that? How do we shorten the time from when evidence suggests we should change our habits to when those habits actually change?
Let's consider nontechnical skills. For instance, surgeons also have habits in how they talk to operating room staff.
Dr. Grose: We often pretend that our behavior doesn't matter. We value the technical and the procedural. It's likely that the technical skill is only about 20 percent of our value to the patient. From the first days of surgical training, that should be the message.
Dr. Ring: If we valued nontechnical skills, they would be appreciated and taught more frequently. Just as we are building a culture in which errors are expected, we also need to build cultures in which we would be expected to change our habits. We'd have a growth mindset.
Dr. Marks: When we teach the communication course, people complain that these techniques and skills—making sure patients get all their questions answered, making sure that you're showing empathy—will take so much time. But in the end, they are huge time savers. I see as many, if not more, patients than all my partners, but I have fewer phone calls to address. I had a receptionist say, "Dr. Marks, your schedule's packed, but you get so few phone messages from patients asking questions. How come?" Because effective communication strategies actually make a difference!
At the end of the day, I leave the office and my partners are still there answering the phone messages, because they didn't address them in the office at the same time. I think that that's a benefit.
Dr. Ring: When we get better at communication strategies, we have less stress.
Dr. Marks: We're happier.
Dr. Ring: We are less susceptible to burnout.
Dr. Resnick: So we can see how clinical habits need reassessment as new data come out. Just to say it has worked well for me for the last 15 years is not enough. When making these changes, going slower, changing one element at a time may work more smoothly than wholesale changes in style. In the long run, not changing, like the example of beta blockers, is not an option.
Learning to listen to our patients and being patient in communicating can help patients understand the best treatment plans as these changes are made. A little extra communication may well reduce unnecessary treatments. Together, not taking for granted new data when we don't believe them, listening to our patients, and constantly improving our treatment habits will improve the care we provide.
David Ring, MD, PhD, is chair of the AAOS Patient Safety Committee, on which Dwight Burney, MD; Michael Pinzur, MD; Alan Reznik, MD; Andrew Grose, MD; and Michael Marks, MD, all serve.
- Lee TH. Eulogy for a quality measure. N Engl J Med. 2007 Sep 20;357(12):1175–1177.
A Painful Tale
One compelling example of how habits can create problems involves approaches to pain relief. A few advocates, supported by pharmaceutical manufacturers, created a narrative that surgeons were under-treating pain, that opioids were effective pain relievers, and that the risk of addiction from opioids was overstated. It turned out that the narrative was false.
The truth is that most of the world effectively manages pain with little or no opioids. In addition, opioids are typically being used to manage stress, distress, and less effective coping strategies that create greater pain intensity. However, opioids not only tend to exacerbate these psychosocial factors, they also distract people from pursuing more effective treatment strategies. Finally, opioids are highly addictive and deadly.
Surgeons need to break several habits to end the current epidemic of opioid misuse, overdose, and death in the United States and Canada. Among the issues that need to be addressed are the following:
- more effective communication strategies and empathy
- ways to postpone discretionary surgery until patients are adequately prepared
- coordinated, collaborative treatment that ensures that psychosocial factors are adequately addressed and opioids are a minimal part of the treatment strategy
- strategies that depersonalize discussions, set reasonable standards, and ensure that patients keep out of trouble
Building these new habits will take work, but that work is important and indispensable. Some useful tools can be found on the AAOS website (aaos.org/Quality/PainReliefToolkit).