Doctor's Orders is a feature in the collaboration between MedPage Today and ABC News. In this monthly segment, we explore medical issues of interest to physicians and patients alike. This month, we look at the difficulties physicians face in incorporating evidenced-based medicine into their practice.
With the amount of research being published in medical journals and presented at meetings, it should not be surprising when a new finding slips by a busy physician.
Nor should it be surprising, then, that some decisions about patient care might be made without benefit of the most recent evidence.
Although experts interviewed by MedPage Today agreed that keeping up with the most current information is challenging, it's unclear exactly how widespread the phenomenon of the outdated doctor is.
"To some degree or another, I think it's very widespread," said Richard Deyo, MD, a professor of evidence-based family medicine at Oregon Health & Science University in Portland.
But he added that it's not a black-and-white issue, because physicians can be up to date in one area and lagging behind in another.
"I think we all are sort of somewhere along a continuum," he said.
Lori Heim, MD, president of the American Academy of Family Physicians, agreed that it's difficult to put a solid number on how many doctors are practicing outdated medicine.
She said a good place to start would be with the numerous studies that have found that many patients do not receive recommended care for various conditions.
One such study, released in the New England Journal of Medicine in 2003, reviewed the care received by surveyed adults in the two years preceding a telephone interview. A review of their medical records found that only 54.9 percent of the time did they get the care recommended for their condition.
However, Heim said, one can't conclude from that data that the other 45.1 percent of the care was delivered by doctors who were not up to date on the most recent evidence.
Perhaps, for instance, a diabetic patient was scheduled to come in for hemoglobin A1c screening but missed the appointment. That might have been listed as a failure to get the recommended care, said Heim, a hospitalist at Scotland Memorial Hospital in Laurinburg, N.C.
Board certification might provide another clue to whether a physician is keeping up to date, Heim said, although doctors who are not board certified might be keeping track of the latest findings and recommendations on their own.
Why Can't Doctors Stay Up to Date?
Regardless of how prevalent the phenomenon of outdated doctors is, experts agree that time constraints are a major reason clinicians have difficulty keeping up with the constant flow of new medical information.
Although reading all of the relevant journals would keep a doctor updated, "it's unrealistic to expect the majority of physicians to go back to the original literature or even to go back to systematic reviews of the original literature," said Gordon Guyatt, MD, of McMaster University in Hamilton, Ontario, who is credited with coining the term "evidence-based medicine."
He said that aside from lack of time, training might explain some of the problem as well.
Most physicians practicing today were not trained in an era of evidence-based practice, Guyatt said, and thus, they didn't learn the skills necessary to keep updated or learn the best sources to reference.
"There's some evidence that we tend to practice much the way we were taught in medical school," Deyo agreed.
There's also some indication that the failure to remain updated might become more of a problem the longer a clinician has been out of medical school.
In a 2005 systematic review in the Archives of Internal Medicine, most studies found a correlation between increasing years in practice and decreasing quality of care.
"Although based on heterogeneous studies, our systematic review of empirical studies evaluating the relationship between clinical experience and performance suggests that physicians who have been in practice for more years and older physicians possess less factual knowledge, are less likely to adhere to appropriate standards of care, and may also have poorer patient outcomes," the study authors wrote.
Deyo didn't discount intellectual curiosity as a contributing factor either.
"Doctors who are more curious and more skeptical are more likely to question what they've been doing routinely and to be open to new ways of approaching problems," he said.
Helping Doctors Keep Track Of It AllAs the use of technology becomes more ubiquitous in all facets of daily life, many physicians are turning to electronic resources available on the Internet and on handheld devices to access the most recent clinical trial findings and guidelines.
MedPage Today and other clinical news services fill part of the need, providing reports of key trials and changes in guidelines on a daily basis.
UpToDate appears to be one of the more popular choices for finding information on a wide range of specialties and Epocrates is a widely used resource for medication information, including drug interactions, contraindications, and dosing.
Other such services include Micromedex, BMJ Clinical Evidence, First Consult, Bandolier, and the American College of Physicians' PIER (Physicians' Information and Education Resource).
In addition, Heim said guidelines, such as those from the U.S. Preventive Services Task Force, are available to be downloaded to handheld devices for quick reference.
In the future, she said, information will be embedded in patients' electronic medical records, alerting physicians to optimal medications, current recommendations, or the need for certain tests.
Some of that is already in place — for example, some records include drug interaction alerts — but more can be done along those lines, Deyo said.
Presumably, the requirement for clinicians to obtain continuing medical education credits also contributes to disseminating the most up-to-date medical information.
However, Guyatt said this might not be enough to ensure the practice of evidence-based medicine because there is no requirement to provide proof that the activities had any effect.
"A more aggressive approach to this would be actually testing people," he said.
Not All Questions Have a Single Answer
But even if strategies could be designed to enhance physicians' abilities to remain up to date, that wouldn't necessarily help when the right approach to a problem is not clear-cut.
As an example, the AAFP's Heim pointed to the recent controversy sparked by the USPSTF's mammography guidelines, which state that women should delay routine screening for breast cancer until age 50.
Other groups, such as the American Cancer Society, have reaffirmed their support for routine screening to begin at age 40.
These types of discrepancies can be confusing for patients, Heim said.
Determining If Doctors Are Up to DatePart of the art of practicing medicine, she said, is using sets of recommendations as guidelines, rather than rigid criteria that must be followed for every patient. Doing so recognizes that each patient comes with a unique constellation of risk factors and might require a different approach, she said.
For this reason, patients might have a a difficult time figuring out whether their physician is keeping up to date.
But both Guyatt and Heim said asking questions of a doctor could provide some clues.
Asking whether certain drugs or approaches are recommended, whether a treatment plan has any downsides, and whether a certain approach is supported by solid evidence will help a patient decide how up-to-date their doctor is.
Heim said that as long as a doctor can explain why a certain strategy has been chosen and why others have been discarded, then he or she is likely following the most recent evidence.
Patients Looking for a Change If patients decide to switch doctors, they might not have many resources to help them choose the most up-to-date physician.
Reliable ratings of doctors are not available, and those provided by doctor-rating Web sites that solicit patient comments might be misleading, Heim said.
For example, she said, a patient might have presented with signs of a viral infection and demanded an antibiotic. If the doctor refused to prescribe an antibiotic then the patient might write a negative review, even though the physician provided appropriate care.
"That's one of the reasons why I think those sites have the potential for giving good information, but they equally have the potential of giving a misinterpretation," Heim said.
She said that checking for board certification might help narrow the search for a new doctor, but that talking to friends and family was probably the best approach.
Importantly, she said, find out how much time a doctor takes discussing things with his or her patients "because I think that is the key to a successful patient-physician relationship."
"If you can't talk to your doc," she said, "it's going to be really hard to figure out whether or not they're staying up to date."