Guest posting by Jesal Shah
Going forward, as identified by many in the first critique session, the most challenging task in our campaign to increase HIV screening by physicians will be the aspect of changing doctor behavior. Most health education efforts are usually patient-centered; moreover, a majority of recent attempts to change doctor and hospital practices have involved top-down, reimbursement and incentive-based mechanisms rooted in economics. This includes remuneration forms, such as salary, capitation, fee-for-service and diagnosis-related groups, as well as reinforcement schemes, like pay-for-performance or financial penalties. However, these strategies are beyond our limited institutional know-how and power.
Increasing physician testing of HIV will be particularly challenging, because screening benefits are not immediate. It’s as Dr. Atul Gawande, a prominent surgeon, health policy expert and author, puts it, “an invisible problem”. In his piece, “Slow Ideas”, Dr. Gawande contrasts the difference between the widespread adoptions of anesthesia, which provided visible benefits and eased doctor’s workflow, and the slow implementation of antiseptic protocols and technologies, which had less immediate returns and required greater doctor effort. Evidence for a certain practice in itself is not enough to build acceptance in the medical community.1,2 While there are very few high quality studies examining physician behavior change models/strategies, the status quo dissemination through publication, pamphlets or guidelines has been shown to be largely ineffective.2,3 These methods are extremely passive and distant; efforts, which are active and interactive, have been demonstrated to be more successful. These include in-person educational outreach or academic detailing. There has also been evidence supporting the utility of reminders or audit-then-feedback approaches. Overall, there are other innovative individual piloted techniques, such as Dr. Vivian Lee’s tactic to capitalize on the intrinsic competitive nature of physicians or Dr. Gawande’s mentorship network, which uses persistent human connection to promote behavior change. However, the most important message ingrained in literature is that multifaceted interventions tackling various barriers is better than a single campaign.2,3 This echoes the suggestions of many at the critique session, including our problem owner. Physician behavior change is an insurmountable barrier when approached narrowly, but in combination, many of the above techniques and others, can hopefully facilitate a change in HIV screening practices.
Sources:
- Gawande, Atul. “Slow Ideas.” The New Yorker. The New Yorker, 29 July 2013. Web. 14 Feb. 2015.
- Grimshaw, J. M., M. P. Eccles, A. E. Walker, and R. E. Thomas. “Changing Physicians’ Behavior: What Works and Thoughts on Getting More Things to Work.” Journal of Continued Education of Health Professionals 22.4 (2002): 237-43. PubMed. Web. 14 Feb. 2015.
- Smith, W. R. “Evidence for the Effectiveness of Techniques to Change Physician Behavior.” Chest 118 (2000): 8-17. PubMed. Web. 14 Feb. 2015.