Whitcomb, Michael E. MD
A recent study suggests that a patient afflicted with one of a number of common disorders is likely to receive appropriate care only half the time.1 This observation is consistent with the results of a number of other studies documenting that doctors too often provide medical care that fails to meet accepted standards of good medical practice. Why is this?
I believe that we in academic medicine must be willing to acknowledge that poor clinical decision making reflects, to a considerable degree, shortcomings in the ways doctors are being educated in this country. This presents a major challenge to the medical education community: How can doctors be educated so that they are truly current on the optimal approaches for diagnosing and managing the clinical conditions they will encounter once they enter practice? And how can they remain current as those approaches change, as they inevitably will?
One of the research reports in this month’s journal sheds some light on the nature of the problem and how it might be addressed. Schilling and colleagues describe a program designed to educate internal medicine residents about the importance of using an evidence-based medicine (EBM) approach to make decisions about the clinical care for outpatients at their institution. In their study, residents rotating through the outpatient clinic were given the opportunity to carry out clinical question exercises. That is, they were given both the time to generate clinical questions relevant to the clinic’s patients and also abundant online resources to help them find answers to those questions. It is significant that the residents were successful in finding answers to almost all of their questions. And it is particularly important to note that those answers affected their decision making most of the time. The study found that it is possible to design an educational experience that shows residents the importance of incorporating the best available evidence into their clinical practices.
But the study’s findings also offer insights into why practicing physicians appear to make decisions that are not informed by evidence that is readily available. Note that the study design allowed residents both the free time to complete the clinical question exercises and also access to a wide array of online resources to seek answers to their questions. Despite that, the residents did not complete the exercises in approximately 30% of the cases. Why? Because of overriding patient care responsibilities. Now, everyone involved in residency training recognizes that residents are extremely pressed for time when they are on busy clinical services. So it should be no surprise that one of the major barriers that must be overcome to incorporate evidence-based decision making into educational programs is to provide the time residents will need to engage in clinical question exercises!
Well, if time is a limiting factor when it comes to incorporating evidence-based decision making into residency training, imagine what this means when this approach is attempted in clinical practice. There can be little doubt that busy practitioners regularly encounter clinical situations that they are uncertain how to manage. It is also clear that they do not have time to seek the evidence they need to make informed patient management decisions, nor do they have sufficient resources to find that evidence.
So what does all this have to do with improving the ways doctors are educated in this country?
To begin, those responsible for the design and conduct of the education of medical students and residents must incorporate clinical question exercises into their curricula. These exercises must become core experiences in all clinical rotations. That means, of course, that residents must be given the time needed to conduct the exercises, both in the outpatient clinic and on inpatient services, and that faculty must be supportive of and guide their efforts. Participating in those exercises will teach the residents the most current approaches for managing certain conditions and will thereby improve the care they give their patients. These experiences will also help them understand the importance of using the best available evidence in providing care. Hopefully, they will take the lesson learned with them when they enter practice.
But what is to be done to help them use that lesson once they are practicing physicians? This is a critically important question, given the rapidity with which new clinical information is being generated and new standards of practice adopted. The simple fact is that the quality of care provided in this country will not become what it should be unless ways can be found to ensure that practicing physicians have the time and resources necessary to answer the complex clinical questions they encounter in their daily practices. It is essential that physicians organize their practices so they can spend the time required to continue to engage in clinical question exercises and to gain access to the online resources they need to successfully complete those exercises. Given the current ways that the delivery of medical care is organized and financed in this country, this presents a major challenge—but it must be overcome.
And there is yet another challenge: To support physicians’ efforts to practice EBM, the country’s continuing medical education (CME) enterprise must change! Physicians must no longer be required, as many are now, to attend standard CME offerings so that they can obtain the credits needed for maintenance of hospital privileges, relicensure, or continuation of certification. Instead, the time, effort, and money they now spend to attend standard CME offerings should be used to allow them to engage in clinical question exercises in their offices or homes.
To sum up: It is crucial that the academic medicine community and the leaders of professional organizations develop a sense of urgency about making the kinds of changes needed in the ways doctors are educated. Those holding leadership positions in medical schools and teaching hospitals must find ways to meaningfully incorporate clinical question exercises into their institutions’ education programs. At the same time, the policies and practices of professional organizations must be changed to recognize that conducting clinical question exercises in practice settings is the best kind of CME doctors can participate in.
All the changes I have urged above will be difficult to implement. But for the sake of future patients—including, perhaps, ourselves—we must begin to make them now.
Michael E. Whitcomb, MD
1 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. NEJM. 2003;348:2635–45.