Physicians resist efforts to standardize care
Physicians resist efforts to standardize care
Non-punitive feedback best way to change behavior
(Editor’s note: David B. Nash, MD, MBA, FACP, is a board-certified internist and the founding director of the Office of Health Policy and Clinical Outcomes at Thomas Jefferson University Hospital in Philadelphia. Nationally recognized for his work in outcomes management, medical staff development, and quality of care improvement, he’s been named by Faulkner & Gray as one of the most influential policy-makers in academic medicine. His national activities include appointment to the JCAHO National Performance Council, vice chair of the Chicago-based American Medical Association Physician Measurement Advisory Committee, and the board of the Foundation for Accountability in Portland, OR. This month, he shares with Hospital Case Management readers his perspective on the problems associated with physician buy-in for critical pathways and how to overcome those problems.)
Q: What are some of the key factors that make physicians resistant to critical pathways?
A: Resistance to critical paths takes several forms and reasons. Probably the No. 1 resistance factor is that physicians feel it places limitations on their autonomy. Really, anything that promotes standardization or limits autonomy is worrisome to them. Second, there’s no good evidence yet that following a critical path will improve [patient] outcomes. So they have not made linkage between changing behavior and improvement in outcomes. I believe doctors would willingly follow a critical path if they knew and were convinced of its improvement in patient outcomes. The same thing goes for a guideline.
So, autonomy, standardization, lack of connectivity to the outcome, and then what I would call lack of efficiency. Without an automated medical record, [pathways] are cumbersome, take extra time, are inefficient, and therefore are not used.
Q: Does it help to involve physicians in the early development of the pathway?
A: That helps certainly in the early going. You know, for the first day. But if you don’t do that as a minimum, you’ll never get any support. If physicians perceive the pathway as a total nursing issue, no one is going to use it.
Q: What is the key to changing physician behavior when it comes to pathways?
A: The most important thing is to give them feedback about performance relative to local peers in a non-punitive way. By the same token, if you can align the financial incentives meaning that you hold them accountable with an economic consequence that changes behavior very fast.
Q: You’ve said in the past that one of the main things that encourages physicians to accept critical pathways is the local reimbursement structure, particularly the presence of capitation.
A: Yes. No question. I wouldn’t even attempt a critical path under fee-for-service. There’s no incentive whatsoever. In an ideal world, with a real risk contract, where every decision has an economic consequence, the pathways could be very useful. But I don’t see that happening anywhere.
Q: Say you’ve got a fee-for-service hospital with a large Medicare population, and they want to use critical paths to lower their expenses. Are there some techniques that case managers can use to try to get greater physician buy-in?
A: No. Not by themselves. I take a very dim view of this. The only way a doctor will listen is if the case manager improves the doctor’s life. If he or she makes all the phone calls, arranges the ambulance, the home care visit, the oxygen, the drugs, then they’ll have an impact. But any barrier thrown in the way and they’re going to have a negative impact.
Q: What about getting support from administrators and trustees, who could then exert a kind of downward influence on physicians?
A: That might work, but you know, the connection between a practicing doctor and the trustees of the institution is tenuous at best. They don’t give a hoot. They have no exposure to the trustees. And since most doctors are not employees . . . That sounds good, but I don’t think it’s realistic.
Q: You’ve also said that all doctors aren’t alike in their attitudes toward cost containment. The older physicians tend to be more resistant than the ones just coming out of medical school.
A: Yeah, that’s definitely a factor here. Older physicians still tend to view the situation as, they’re captains of the health care ship. And there’s no room on the bridge for two or three captains. Again, if the critical path implementation team can help the doctor, well, then maybe they’ll pay attention. But so far I’ve seen no evidence that this is the case. In fact, all the evidence is in the reverse.
For more information, contact David B. Nash, MD, MBA, FACP, associate dean and director of health policy and clinical outcomes, Thomas Jefferson University Hospital, 1015 Walnut St., Ste. 621, Philadelphia, PA 19107-5099. Telephone: (215) 955-6969.
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