Why Are We Slow to Stop Inappropriate Care?

By | November 13, 2020

One of our shortcomings as health care professionals is our acceptance of evidence-based medicine, especially when the data proves that abandoning practices is required.  And despite robust, research cataloging practices, that add little value, such activities remain widespread at a considerable cost and increasing the likelihood to harm.

As professionals, the question remains, “Why are we so slow to move away from our practices when we have been proven wrong?” One possibility is in the statement itself. The vast majority, if not all clinicians wake up every day thinking about how they can help their fellow human beings. Psychologically, it is tough for me to tell myself that I may have been wrong, and thus, possibly hurting those whom I am entrusted to serve. Therefore, I hold onto my beliefs to avoid the emotional consequence that ensues.

Additionally, how our governing bodies allow medicines and procedures to come to market amplifies the appropriateness conundrum. Frequently, we adopt treatments and technology deemed safe, and yet, they are not necessarily a superior option. Furthermore, it is often not until countless years following the adoption of a treatment that our science and research catch up to the validity of utilization; meaning, “The cat is already out of the bag!”

Thus, de-adopting low-value care falls into three categories; evidence, eminence, and economics. As our evidence of appropriateness follows mass use, eliminating a treatment from our thinking is arduous based on our human behaviors, especially the emotional and habitual components. Eminence, or what our leaders tell us, also plays a critical role.

For the same reason, we have difficulties altering our behaviors. Furthermore, our medical societies and subject matter experts also play a critical role in our continuation of non-evidence-based activities. Very often initially they are reticent even to announce their stances on a topic. When they do, they state their pronouncements as “guidelines” or “recommendations,” which are not statements of needed change. Unequivocally, we are a profession of differing opinions and have a desire for consensus. As we focus on how to placate ourselves, we run the risk of hurting others.

Economics plays a critical role as well. At times we are inadvertently financially rewarded for continuing a certain low-value procedure or treatment and then not penalized in our payment models when we treat in a manner that does not adhere to the evidence. Yes, medicine is an art, and people are individuals, yet we are quite far from the appropriate treatment variation that allows for this argument. Value-based payment models may address the economic complexities of appropriateness.

Regardless of the reasons, we must continue to strive to manage the polarity of appropriate care for those we serve. As a profession, there is an obligation to continuously question ourselves in a positive manner rather than attempting to call each other out in negative, behavioral tones. Assuredly, we are on a trajectory towards better care and must accept that wrong turns occur, and our pace is rarely consistent. These are part of our journey and are part of the process. Let us continually strive for improvement and adherence to the evidence as it becomes available.