• Information overload

    After documenting the rapid rise in number of clinical studies, authors of the Institute of Medicine’s Knowing What Works in Health Care (page 36) conclude,

    For physicians—and patients—who are motivated enough to read through and assess all of the relevant individual clinical studies on their own, keeping current is an arduous, if not impossible, task. Given the variable quality of the research and its limited generalizability, these providers and patients are faced not only with reconciling vastly different research findings but also with scrutinizing each study’s methodology in detail to ensure that the study has been well designed, that the analyses have been well performed, and that the results apply to their particular clinical circumstance (Abramson, 2004). This expectation is unrealistic, especially given that today’s medical residents frequently lack the knowledge in biostatistics necessary to interpret the findings of published clinical research (Windish et al., 2007). These findings illustrate the need for a system that can make sense of all of the data that currently exist, as well as the new knowledge that is now being generated.

    Naturally, systematic reviews and clinical guidelines help, but the report documents an explosive number of those too, or none at all in some areas. This strikes me as a real challenge to the notion of consumer-directed health care, at least for consumers who want to make evidence-based choices. Those that just want to make it up as they go along need not be concerned about the volume of evidence.

    But it’s worse than that. This strikes me as a real challenge for the very experts on which many of us rely, the physicians we consult for advice and care. Is it possible to assess the degree to which one’s physician is keeping up with the literature? There can’t be very many of them that do so thoroughly, given the challenge of the task and the fact that they must spend some of their day actually delivering care. They probably sleep some too, and eat, and have lives, as they should!

    I’m not sure what to do about all this, since the volume of  clinical studies is likely to keep rising as we fund more of them. We need those studies. But we also need the information to be accessible and usable. I know PCORI is all over this concept, but the jury is out as to whether it can do anything substantial about it.

    No doubt there are information technology solutions. That’s also probably another domain into which we could sink a lot of money for little return. Just as throwing an iPad at a high school student doesn’t cause him to learn calculus, putting everything into a searchable database won’t make doctors and patients sudden masters of the evidence.

    There’s a real need for answers. The wealth of our nation and our well being depend on them. I don’t have any right now.


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    • I don’t think it is reasonable to have every doctor keep up to date with all of the primary literature in their field… even if it is a narrow specialty field. I think that most “average” physicians find this to be impossible.
      A much better solution to have “experts” review the literature and keep guidelines up to date. Then, physicians could follow the latest guidelines and be assured of delivering reasonably competent care.
      Of course, this leads to the problems you have pointed out with the current sad state of guidelines… too many or too few depending on medical condition. However, this should be an opportunity to address this problem as a high priority through PCORI, AHRQ, specialty societies, HHS, etc. Unfortunately, this becomes a political battle on many levels so we will probably be left with the current mess of guidelines for some time.
      I still believe following a guideline is much better than most physicians practice which is an opaque mashup of medical school training, “some article I read”, and their (unique and biased) anecdotal experience.

    • Hospitals, HMOs and insurers should all realize that hiring uninformed doctors is bad for business. So the starting point should be linking 5% of a doctor’s pay and schedule based around keeping up to date with best new practices. Why spend 7 years in med school/residency if you’re just going to let your cutting edge knowledge shrivel up?

      I am a big fan of the NEJM practice cases http://www.nejm.org/medical-articles/clinical-problem-solving – I think they make learning concepts far more interesting to a clinician than reading just a round-up of new scientific findings. Digital subscriptions to services like these should become standards. Doctor’s could subscribe to three or four RSS feeds depending on their specialty (e.g., an orthopedic surgeon would have a “Structure of Care” module, a “Surgical Methods update” module and a “Clinical outcomes of common orthopedic procedures” module. Each of these could be curated to highlight recent developments, and a doctor could spend one hour every week covering the modules that fit his practice. Every week a doctor falls behind, his salary could be decreased by 1 or 2%, making doctors who don’t keep up to date worth less.

      The feeds could be curated by professional editors (like journals) but with constant input from physicians on the front lines. If you were a surgeon and you thought the “Surgical Methods Update” had not given enough attention to recent developments in a certain topic, you would be encouraged to write the curators and maybe even reimbursed for improving the feed.

      An alternate way of keeping docs “up to date” would be to have pop-ups appear whenever doctors encountered a patient with a condition where medical knowledge has recently changed. This interrupting at the point of care might seem advantageous at first – but doctors will continuously fall behind and many will be emotionally turned against a system that tells them they don’t know what they’re doing for the patient standing in front of them.

      How would these learning modules be paid for? Provider companies will realize it’s well worth their effort to invest a small portion of their doctor’s time into keeping everyone on the same page. If 27 year old residents and 59 year old attendings don’t agree on how to proceed, care will be compromised.