The physician’s experience of changing clinical practice: a struggle to unlearn
Tóm tắt
Changing clinical practice is a difficult process, best illustrated by the time lag between evidence and use in practice and the extensive use of low-value care. Existing models mostly focus on the barriers to learning and implementing new knowledge. Changing clinical practice, however, includes not only the learning of new practices but also unlearning old and outmoded knowledge. There exists sparse literature regarding the unlearning that takes place at a physician level. Our research objective was to elucidate the experience of trying to abandon an outmoded clinical practice and its relation to learning a new one. We used a grounded theory-based qualitative approach to conduct our study. We conducted 30-min in-person interviews with 15 primary care physicians at the Cleveland VA Medical Center and its clinics. We used a semi-structured interview guide to standardize the interviews. Our two findings include (1) practice change disturbs the status quo equilibrium. Establishing a new equilibrium that incorporates the change may be a struggle; and (2) part of the struggle to establish a new equilibrium incorporating a practice change involves both the “evidence” itself and tensions between evidence and context. Our findings provide evidence-based support for many of the empirical unlearning models that have been adapted to healthcare. Our findings differ from these empirical models in that they refute the static and unidirectional nature of change that previous models imply. Rather, our findings suggest that clinical practice is in a constant flux of change; each instance of unlearning and learning is merely a punctuation mark in this spectrum of change. We suggest that physician unlearning models be modified to reflect the constantly changing nature of clinical practice and demonstrate that change is a multi-directional process.
Tài liệu tham khảo
Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104:510–20.
Dewey J. Human nature and conduct: an introduction to social psychology. 1st ed. New York: Holt; 1922.
Nilsen P, Roback K, Brostrom A, Ellstrom PE. Creatures of habit: accounting for the role of habit in implementation research on clinical behaviour change. Implement Sci. 2012;7:53.
Ubel PA, Asch DA. Creating value in health by understanding and overcoming resistance to de-innovation. Health Aff (Millwood ). 2015;34:239–44.
Perkins MB, Jensen PS, Jaccard J, Gollwitzer P, Oettingen G, Pappadopulos E, et al. Applying theory-driven approaches to understanding and modifying clinicians’ behavior: what do we know? Psychiatr Serv. 2007;58:342–8.
Godin G, Belanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals’ intentions and behaviours: a systematic review of studies based on social cognitive theories. Implement Sci. 2008;3:36.
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458–65.
Cochrane LJ, Olson CA, Murray S, Dupuis M, Tooman T, Hayes S. Gaps between knowing and doing: understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof. 2007;27(2):94–102.
May C, Finch T, Mair F, Ballini L, Dowrick C, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res. 2007;7.
Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:53.
Davies P, Walker AE, Grimshaw JM. A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implement Sci. 2010;5:14–5.
Cane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.
Francis JJ, O'Connor D, Curran J. Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implement Sci. 2012;7:35.
PerryUndem Research/Communication. Unnecessary tests and procedures in the health care system. What physicians say about the problem, the causes, and the solutions Results from a National Survey of Physicians. 1-33. 5-1-2014. PerryUndem Research/Communication. The ABIM Foundation.
van Bodegom-Vos L, Davidoff F, Marang-van de Mheen PJ, Implementation and de-implementation: two sides of the same coin? BMJ QUal Saf 2016. doi: 10.1136/bmjqs-2016-005473. [Epub ahead of print]
Gnjidic D, Elshaug AG. De-adoption and its 43 related terms: harmonizing low-value care terminology. BMC Med. 2015;13:273.
Prasad V, Ioannidis JP. Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implement Sci. 2014;9:1.
Bouton ME. Why behavior change is difficult to sustain. Prev Med. 2014;68:29–36.
Savage T, Ziemke T. Learning and unlearning mechanisms in animats and animals. Adaptive Behav. 2000;8:97–128.
Bouton ME. Context, ambiguity, and unlearning: sources of relapse after behavioral extinction. Biol Psychiatry. 2002;52(10):976–86.
Myers KM, Davis M. Mechanisms of fear extinction. Mol Psychiatry. 2007;12(2):120–50.
Dunne G, Askew C. Vicarious learning and unlearning of fear in childhood via mother and stranger models. Emotion. 2013;13(5):974–80.
Becker K. Individual and organisational unlearning: directions for future research. International Journal of Organisational Behaviour. 2005;9:659–70.
Rushmer R, Davies HT. Unlearning in health care. Qual Saf Health Care. 2004;13 Suppl 2:ii10–5.
Becker K. Unlearning as a driver of sustainable change and innovation: three Australian case studies. International Journal of Technology. 2008;42:89–106.
Becker K. Facilitating unlearning during implementation of new technology. Journal of Organzational Change Managment. 2013;23:251–68.
Coombs C, Hislop D, Holland J, Bosley S, Manful E. Exploring types of individual unlearning by local health-care managers: an original empirical approach. Health Services and Delivery Research. 2013;1:1–146.
Hislop D, Bosley S, Coombs C, Holland J. The process of individual unlearning: a neglected topic in an under-researched field. Manag Learn. 2014;45:560.
Manchester J, Gray-Miceli DL, Metcalf JA, Paolini CA, Napier AH, Coogle CL, et al. Facilitating Lewin's change model with collaborative evaluation in promoting evidence based practices of health professionals. Eval Program Plann. 2014;47:82–90.
van Leijen-Zeelenberg JE, van Raak AJ, Duimel-Peeters IG, Kroese ME, Brink PR, Ruwaard D, et al. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014;14:149.
Cegarra-Navarro J, Cepeda-Carrion G, Eldridge S. Balancing technology and physician–patient knowledge through an unlearning context. Int J Inf Manag. 2011;31:420–7.
Cegarra-Navarro J, Wensley AK, Sanchez PM. A conceptual framework for unlearning in a homecare setting. Knowledge Manage Res Pract. 2014;12(4):375–86.
Gutierrez J, Cegarra Navarro J, Cepeda Carrion G, Leal Rodriguez A. Linking unlearning with quality of health services through knowledge corridors. J Bus Res. 2015;68:815–22.
Macdonald G. Transformative unlearning: safety, discernment and communities of learning. Nurs Inq. 2002;9:170–8.
Sola I, Carrasco JM, Del Diaz CP, Gracia J, Orrego C, Martinez F, et al. Attitudes and perceptions about clinical guidelines: a qualitative study with Spanish physicians. PLoS One. 2014;9, e86065.
Albanese M, Mejicano G, Xakellis G, Kokotailo P. Physician practice change I: a critical review and description of an Integrated Systems Model. Acad Med. 2009;84:1043–55.
Lugtenberg M, Zegers-van Schaick JM, Westert GP, Burgers JS. Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implement Sci. 2009;4:54. doi:10.1186/1748-5908-4-54. PubMed PMID: 19674440; PubMed Central PMCID: PMC2734568.
Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, et al. Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci. 2016;11:40.
LeTourneau B. Managing physician resistance to change. J Healthc Manag. 2004;49:286–8.
Montini T, Graham ID. “Entrenched practices and other biases”: unpacking the historical, economic, professional, and social resistance to de-implementation. Implement Sci. 2015;10:24.
Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, et al. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med. 2015;13:255.
Silverstein W, Lass E, Born K, Morinville A, Levinson W, Tannenbaum C. A survey of primary care patients’ readiness to engage in the de-adoption practices recommended by Choosing Wisely Canada. BMC Res Notes. 2016;9:301.
Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. Thousand Oaks, CA: SAGE Publications, Inc.; 2006.
Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd ed. CA: Sage Publications; 2007.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International J Qual Health Care. 2007;19:349–57.
Bolen S, Feldman L, Vassy J, Wilson L, Yeh H-C, Marinopoulos S, et al. Systematic review: comparative effectiveness and safety of oral medications for type 2 diabetes mellitus. Annals Internal Medicine. 2007;147:386–99.
Qaseem A, Vijan S, Snow V, Cross J, et al. Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targets. A guidance statement from the American College of Physicians. Ann Intern Med. 2007;147:417–22.
Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012;156:147–9.
Lewin K. Group decision and social change. Readings in Social Psychology. 1947;3:197–211.
Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv in Health Sci Educ. 2009;14:27–35.
Sun R, Slusarz P, Terry C. The interaction of the explicit and the implicit in skill learning: a dual-process approach. Psychol Rev. 2005;112(1):159–92.
Presseau J, Johnston M, Heponiemi T, Elovainio M, Francis JJ, Eccles MP, et al. Reflective and automatic processes in health care professional behaviour: a dual process model tested across multiple behaviours. Ann Behav Med. 2014;48(3):347–58.
Aron DC, Lowery J, Tseng CL, Conlin P, Kahwati L. De-implementation of inappropriately tight control (of hypoglycemia) for health: protocol with an example of a research grant application. Implement Sci. 2014;9:58.
Andersen LP, Nielsen H. Peptic ulcer: an infectious disease? Ann Med. 1993;25(6):563–8.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med. 1991;324(12):781–8.
Howells J, Mitev N. A sceptical approach to the concept of unlearning: empirical evidence on learning and unlearning in two major process studies of ICT systems implementation. Core-2008-02, 1-33. 2013. Centre for Organizational Renewal and Evolution.
Howells J, Scholderer J. Forget unlearning? How an empirically unwarranted concept from psychology was imported to flourish in management and organisation studies. Manag Learn. 2016;47:443–63.