What’s up doc?
These days doc doesn’t always know
By SUSAN IPAKTCHIAN
In his work at Stanford’s internal medicine clinic, Randall Stafford has become accustomed to re-educating both residents and their patients. Both groups tend to believe that the latest medications will produce the best outcomes, but Stafford always reminds them that “newest” isn’t necessarily “best.”
“It’s a striking example of physicians trying to meet their patients’ requests but not necessarily focusing on the right thing,” says Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center.
Not that Stafford is blaming physicians. Rather, he says the problem lies with the U.S. health-care system, which places an increasing load of demands — from insurance companies, government agencies, patients and pharmaceutical companies — on their white-coated shoulders. “The time pressures and a focus on acute medical issues get in the way of optimal treatment that follows the best evidence,” Stafford says.
The question of how quickly physicians change their practices in response to clinical trial evidence is at the heart of Stafford’s own research. “We devote a good deal of resources and effort to developing guidelines that suggest how physicians should practice, and it’s only natural to compare those guidelines with what actually happens,” he says. “That sort of comparison is done too infrequently.”
Stafford uses national databases and other methods to analyze changes in physician practices. He’s explored prescribing patterns (for anti-inflammatories, antibiotics, hypertensives and hormone therapy, to name a few) as well as doctors’ use of electrocardiograms, diet and exercise counseling, and Caesarean sections.
The results are mixed, although physicians tend to be slow to change their practices. For instance, Stafford examined reactions to the finding that low-cost diuretics were as effective and posed fewer health risks than more expensive medications for treating hypertension. Prescribing patterns changed slowly with a 54 percent decline in alpha-blocker prescriptions over a period of three years. By contrast, the highly publicized findings about the dangers of hormone therapy resulted in a 56 percent decrease in prescriptions for the estrogen/progestin combination in less than a year.
A complex blend of factors — physician training, pharmaceutical marketing, patient knowledge and demands, health insurance restrictions — affects the adoption of new medical practices and health behaviors, Stafford points out, noting that some factors can be modified. By pinpointing those factors and designing strategies that improve health care using proven methods, he hopes to help Americans get the most from the billions of dollars invested in biomedical research and health care.
First, researchers should more actively disseminate their findings and any resulting guidelines to physicians and consumers. This could be accomplished by reaching out to the popular media rather than solely relying on publication in scientific journals. Second, physicians should monitor how well their practices match up with published evidence and with those of their colleagues. Electronic medical records may provide important help in this regard. And finally, consumers must take a more active role in maintaining and improving their health rather than hoping for a quick fix in the form of pills and procedures.
The financial implications of a more evidence-based approach to health
care could be enormous, Stafford says. “We expend a huge amount
of resources on medical care and it’s unclear whether we maximize
our return on that investment.”
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