Becoming an Information Master

One of the greatest pains to human nature is the pain of a new idea.

Medicine, like most professions, is in danger from a tsunami created by the information explosion of the 1990s. This tidal wave of information, as well as its push-button accessibility, is threatening the basic foundations of the profession. The clinician is no longer considered the exclusive interpreter of medical wisdom and the sole arbiter of what is best for patients. Government agencies, managed care organizations, the news media, and advocacy groups all use medical information to influence patient care. All of these groups are constantly monitoring medical research to determine whether we are changing the way we practice when new and better information comes along.

In this article, we focus on how we learn from this information. From that perspective we will talk about how to change, since change is the ultimate goal of information use.

Why is change so important? The advent of new diagnostic tests, procedures, and medications make it necessary for us to change on a regular basis. Every clinician must change practice habits many times during a career. One can choose either to lead change or be dragged along behind it.

Our article is not about reacting to outside attempts to induce change, the carrots or sticks used by agencies and organizations to motivate us do something different. It is about truly being a master of information rather than its servant.

Information and change: How we learn

At the beginning of life, our minds are like empty shelves in a grocery store. As we learn, we stock them with units of information. Much of our lives are spent filling those shelves with the things we have learned.

Like bread in the grocery store, our information becomes stale and eventually expires. As we continue the lifelong learning process, we replace what has gone stale with fresh units of information. Unfortunately unlike the grocer’s shelves, the information gathered during medical school and in practice does not have an expiration date stamped on it. As a result, we may not know when our existing information has become stale or invalid. And similar to a loaf of stale bread, the information that we store can appear fresh, even though it is past its expiration date.

This lack of expiration labeling makes the job of the information master much more difficult. We need to search continually for new information to discover when our existing information has become outdated.

Think about the information that has become available in the last 10 years: antibiotics for treatment of peptic ulcer disease, the ineffectiveness and possible harm of patching corneal abrasions, therapy of deep venous thrombosis changing from 14 days of hospitalization to at-home treatment, and angiotensin-converting enzyme inhibitors and b-blockers used instead of digoxin as the cornerstone of heart failure therapy. To do what is best for patients, we need to identify new information and assimilate it into daily practice. Maintaining best practices requires change.

In our first paper, we distinguished “data” and “information” from the “knowledge” and “wisdom” that are the results of our brainpower. As a critical prerequisite to change, we must separate our view of ourselves from the information we have. Our value—to individual patients as well as society—is based on our ability to think using the information we accumulate.^11,12 Descartes said, “I think, therefore I am,” not “I know a lot, therefore I am.” We can only think best when we have the best information. Information is useless without reflection and questioning.

Too often we get so attached to hard-earned knowledge that we get defensive when it is challenged by new information. We might interpret evidence requiring us to change as an assault on the integrity of our previous education (and so, in some ways, an attack on our very being).

But information only affects our decisions: It does not change our ability to think. The correct decisions of 5, 10, or 20 years ago were based on the best information available at that time. New evidence, however, requires that we change the way we think about things.

Barriers to Change

Humans spend their lives resisting change.

The idea of change seems self-evident: If people want to change, they will. However, it is not that simple. Many smokers want to quit. Many overweight people want to become svelte. There is a large gulf between wanting to change a behavior and actually changing it.

Several barriers get in the way of this process of change. Fear, discomfort with ambiguity, guilt, and loss of control top the list of reasons for resistance to change. The Figure 1 illustrates some of the factors that have an impact on the process of change. Another barrier is a lack of awareness of information. Sometimes, even when information is found, it may not seem trustworthy. We may think that the information is flawed, that our patients are different from those in the study, or that the results are not applicable to a particular patient. Or we may be uncomfortable with straying from the pack. Fear of lawsuits, bowing to authority, and the “we’ve-never-done-it-that-way-before” syndrome can keep us from doing something new and different.

Changing Yourself

For most doctors, change is virtually a routine part of life…. The alternative to controlling the process of change is to be controlled by it, and in dramatic cases, to experience professional or personal collapse.

Taking control of learning requires the prerequisites outlined in the Table 1. The process of change has 5 steps: obtaining new information; deciding, based on that information, that a new approach may be better; deciding to use a new approach; implementing it; and confirming that this change is beneficial. Below are several ideas to make these steps easier.

Become a Reflective Clinician

The process of change begins with reflection in action: thinking about what you are doing while you are doing it. This introspection, often confused with clinical experience, allows you to identify, though not necessarily fix, those aspects of practice you feel uncertain about. The first requirement of change is the identification of tried-and-true, yet not wholly satisfactory, modes of patient management. Ask yourself: What am I doing in my practice, and why am I doing it?

The next step is to open our minds to the idea of change. Our value lies in our analytical skills and our ability to synthesize information, not in being storehouses of facts. We need to work hard to cultivate the talent to question all things, especially our own knowledge.

Once our minds are open, we need to listen. We have to hear what patients are saying between the lines. We have to take the letters from insurance carriers concerning prescribing or referral habits out of the trash and see what they have to say. Find out what is behind their pronouncements, not for argument’s sake, but to analyze and understand the information.

Many of us get defensive when we realize that our practice habits can be improved. We are not used to nonsuccess of any sort. We get embarrassed, feel threatened and then guilty. Anything short of perceived perfection is threatening. Information mastery means realizing there is much we do not know. The first step to knowledge is the confession of ignorance. We need to look for ways to become free of self-deception (take off the rose-colored glasses) by looking beyond the dogma.

Determine Patient-Oriented Outcomes of Importance

There are many questions that have not been answered by the science of medicine. We know much less about the optimal care of patients than most of us care to confess.

Information masters know that there is much work to be done to shore up the science that supports medicine. Recent studies have shown that only approximately half of the best clinical information is based on good evidence. For example, the latest anticoagulation guidelines were developed using the highest quality evidence only 44% of the time.

Nonetheless, everyone needs to figure out the patient-oriented outcomes of importance to their patients. Start with the concept that patients want to live long healthy symptom-free productive lives. What are you willing to do to meet this goal? Independent thinking is a necessary requirement for exploration of new ideas.

Develop Information Skills

There are several skills necessary for becoming an effective information manager. All of us need to develop quick ways of identifying new information and evaluating its validity. We can begin by being discriminating in our sources of information, since the easiest source may not be the best.

Hunt and forage. Most of us seek information in 2 ways. Sometimes we hunt, searching for information to answer specific questions. To hunt for information, we need to assemble sources that will allow us to find what we need in the least amount of time. Some computerized sources of information are designed to lead us to well-validated, predigested information within 1 minute of starting. InfoRetriever, The Cochrane Database of Systematic Reviews, and Best Evidence, are CD-based databases that provide validated information in an easily searchable format.* In addition, various Internet sites are available that give access to valid, predigested information, including this journal’s POEMs online (www.infopoems.com), Bandolier (www.jr2.ox.ac.uk/Bandolier), Dr’s Desk (drsdesk.sghms.ac.uk), the TRIP database (www.ceres.uwcm.ac.uk), and DynaMed (www.dynamicmedical.com).

At other times we forage; rummaging for new information. To stay up to date, it is necessary to develop an information-gathering plan. This is not as onerous as it sounds. We can use POEM bulletin boards to keep on top of new information. These sources, such as Evidence-Based Practice, Evidence-Based Medicine, and ACP Journal Club, use specific criteria to identify and present the results of studies that investigate patient-oriented outcomes.

We need to forage and hunt to keep up to date and to find information as necessary. Without both, you do not know what you are looking for and cannot find it when you do.

Use YODAs. In the Star Wars mythology, Yoda is a mentor who provides guidance and interpretation. In a previous paper we defined a YODA—Your Own Data Analyzer—as a person or source of information that can take the best information available, analyze it to determine whether it is valid, and interpret it within the context of clinical practice. In medical practice, we need to identify our own YODAs and also be one for others.

A YODA can be a colleague or someone in the community who has demonstrated an understanding of evidence-based medicine. We need to identify our YODAs, and ask them regularly for their thoughts on issues we confront in practice. Do not rely solely on their pronouncements, however; ask them to identify the evidence supporting their assertions.

An alternative to local YODAs are published YODAs, such as The Cochrane Library a database of meta-analyses, or the POEMs column and the evidence-based reviews in The Journal of Family Practice. Both the Journal’s evidence-based reviews section and the Cochrane database start with a clinical question and employ all of the valid research literature on the topic to formulate an answer based on the best available evidence. The Cochrane database is available on compact disk or at the Cochrane Collaboration’s Web site (www.updateusa.com/clibip/clib.htm).

In addition to identifying YODAs, we should strive to become one. No one can be an expert on everything in medicine, but we can all become one on a few topics that we find especially interesting. For those topics, know the literature. Become a resource. Once we have developed the confidence in our own YODA-hood, we can be one for others. Our positive influence on our colleagues will help them and their patients.

Be discriminating in CME participation. Choose your continuing medical education (CME) time carefully. The research is quite clear: Most people retain very little information presented at CME conferences. Two options present themselves: (1) pick useful CME; or (2) use the opportunity as an excuse to go to a fun locale. If you decide on the first option, work to identify CME opportunities that use interactive formats, such as workshops during which YODAs present evidence that can be evaluated for validity. Not all evidence-based medicine CME conferences meet this criterion.

Whether listening to a speaker or talking with a colleague or consultant, keep in mind the golden question: “That’s interesting … what evidence supports that idea?” There are hundreds of ways to ask that question diplomatically. It is not a judgment or an accusation, but simply a way to further understand the strength of a recommendation or clinical practice. If it is not a valid POEM, it is not necessarily useful information.

You may also need to spend some time tracking down the information supporting the speaker’s conclusions. Speakers may not have that information at their fingertips but they may be able to point you in the right direction. Always write down your questions for follow-up later.

Learn by doing. We learn best by doing. Consider setting up a practice-based small-group CME.³³ Set aside time each month to work with colleagues to answer clinical questions. Decide on a clinical question, find information to answer it, and use the monthly meeting time to present and discuss the information with others in the group.

The development of practice protocols or guidelines is an easy outgrowth of this type of CME activity. Many opportunities exist to get involved in local guideline or protocol development at your hospital or managed care organization. Use the opportunity to learn and teach. Guidelines have their greatest impact on those who are instrumental in developing them.

Finally, we should teach our pharmaceutical representatives to bring us POEMs. Tell them that physicians do not have time for interesting but irrelevant information; we want evidence that shows their product is safer, more tolerable, more effective, less expensive, or simpler to use than the alternatives. Do not let them schedule reminder appointments; tell them we do not want to see them unless their information is new and important to our patients.³⁴

Make the Change a Part of Practice

We are not finished once we have simply decided to change. We have to make the change part of our practice routine. Our subconscious tendency is to resist change—especially large changes. Doing something differently requires more than good intentions.

We should start by sharing what we have learned with others. One of the best ways to learn something is to teach it to others. (As we noted in a previous article, the only one who really learns anything from a CME presentation is the presenter.²)

Another method of incorporating change is to break down the barriers to change by getting everyone on the same team. Relationships within a medical practice (or in a medical community) can be parasitic, competitive, or complementary. Medical offices staffed by personnel with parasitic relationships do not succeed because they destroy the practice from within. Competitive relationships within a practice—pitting physicians against one another or professional staff against administrative staff—drain energy from everyone. Complementary relationships in a practice, however, overcome barriers, foster an atmosphere of teamwork, and most important, allow everyone to teach everyone else. In one of our offices, the expert source of vaccine-related information is not an physician or a pharmacist, but a nurse who can quote dosing information and Centers for Disease Control recommendations. She regularly updates the staff on vaccination issues.

Another idea is to change processes rather than ourselves. Some behaviors can not change until we change the underlying structure of practice.³⁵ This is a central concept of continuous quality improvement. For example, if we decide to let men make their own decision regarding prostate cancer screening, we must make sure that patient information sheets about the test are within easy reach. And instead of having to remember to examine the feet of every patient with diabetes at each visit as outlined in recent guidelines, we can institute a policy in which all of these patients are instructed to take off their shoes and socks at each visit.

Everyone in the office can be involved in process change. Involve all of the staff, from the nurses to the administration staff, in identifying patients who need a flu shot or who are still smoking, so one person does not have to remember it all. Be goal oriented. Keep the big picture in mind. Set the boat’s destination, and let everyone help do the rowing.

Conclusions

Change before you have to.

Change begins with a questioning mind searching for new and better information. The development of the skills necessary to find and evaluate information should follow. And implementing the changes of ingrained habits is the final and most difficult part of the process.

Evidence that matters is information that requires a change in practice. Information mastery is necessary because of the core value of all health care: we strive to do what is best for patients. When presented with valid evidence that will improve the quality of care of our patients, we must accept the challenge and the responsibility of changing our behavior and implementing those changes in our practices.

One of the greatest pains to human nature is the pain of a new idea.

Medicine, like most professions, is in danger from a tsunami created by the information explosion of the 1990s. This tidal wave of information, as well as its push-button accessibility, is threatening the basic foundations of the profession. The clinician is no longer considered the exclusive interpreter of medical wisdom and the sole arbiter of what is best for patients. Government agencies, managed care organizations, the news media, and advocacy groups all use medical information to influence patient care. All of these groups are constantly monitoring medical research to determine whether we are changing the way we practice when new and better information comes along.

In this article, we focus on how we learn from this information. From that perspective we will talk about how to change, since change is the ultimate goal of information use.

Why is change so important? The advent of new diagnostic tests, procedures, and medications make it necessary for us to change on a regular basis. Every clinician must change practice habits many times during a career. One can choose either to lead change or be dragged along behind it.

Our article is not about reacting to outside attempts to induce change, the carrots or sticks used by agencies and organizations to motivate us do something different. It is about truly being a master of information rather than its servant.

Information and change: How we learn

At the beginning of life, our minds are like empty shelves in a grocery store. As we learn, we stock them with units of information. Much of our lives are spent filling those shelves with the things we have learned.

Like bread in the grocery store, our information becomes stale and eventually expires. As we continue the lifelong learning process, we replace what has gone stale with fresh units of information. Unfortunately unlike the grocer’s shelves, the information gathered during medical school and in practice does not have an expiration date stamped on it. As a result, we may not know when our existing information has become stale or invalid. And similar to a loaf of stale bread, the information that we store can appear fresh, even though it is past its expiration date.

This lack of expiration labeling makes the job of the information master much more difficult. We need to search continually for new information to discover when our existing information has become outdated.

Think about the information that has become available in the last 10 years: antibiotics for treatment of peptic ulcer disease, the ineffectiveness and possible harm of patching corneal abrasions, therapy of deep venous thrombosis changing from 14 days of hospitalization to at-home treatment, and angiotensin-converting enzyme inhibitors and b-blockers used instead of digoxin as the cornerstone of heart failure therapy. To do what is best for patients, we need to identify new information and assimilate it into daily practice. Maintaining best practices requires change.

In our first paper, we distinguished “data” and “information” from the “knowledge” and “wisdom” that are the results of our brainpower. As a critical prerequisite to change, we must separate our view of ourselves from the information we have. Our value—to individual patients as well as society—is based on our ability to think using the information we accumulate.^11,12 Descartes said, “I think, therefore I am,” not “I know a lot, therefore I am.” We can only think best when we have the best information. Information is useless without reflection and questioning.

Too often we get so attached to hard-earned knowledge that we get defensive when it is challenged by new information. We might interpret evidence requiring us to change as an assault on the integrity of our previous education (and so, in some ways, an attack on our very being).

But information only affects our decisions: It does not change our ability to think. The correct decisions of 5, 10, or 20 years ago were based on the best information available at that time. New evidence, however, requires that we change the way we think about things.

Barriers to Change

Humans spend their lives resisting change.

The idea of change seems self-evident: If people want to change, they will. However, it is not that simple. Many smokers want to quit. Many overweight people want to become svelte. There is a large gulf between wanting to change a behavior and actually changing it.

Several barriers get in the way of this process of change. Fear, discomfort with ambiguity, guilt, and loss of control top the list of reasons for resistance to change. The Figure 1 illustrates some of the factors that have an impact on the process of change. Another barrier is a lack of awareness of information. Sometimes, even when information is found, it may not seem trustworthy. We may think that the information is flawed, that our patients are different from those in the study, or that the results are not applicable to a particular patient. Or we may be uncomfortable with straying from the pack. Fear of lawsuits, bowing to authority, and the “we’ve-never-done-it-that-way-before” syndrome can keep us from doing something new and different.

Changing Yourself

For most doctors, change is virtually a routine part of life…. The alternative to controlling the process of change is to be controlled by it, and in dramatic cases, to experience professional or personal collapse.

Taking control of learning requires the prerequisites outlined in the Table 1. The process of change has 5 steps: obtaining new information; deciding, based on that information, that a new approach may be better; deciding to use a new approach; implementing it; and confirming that this change is beneficial. Below are several ideas to make these steps easier.

Become a Reflective Clinician

The process of change begins with reflection in action: thinking about what you are doing while you are doing it. This introspection, often confused with clinical experience, allows you to identify, though not necessarily fix, those aspects of practice you feel uncertain about. The first requirement of change is the identification of tried-and-true, yet not wholly satisfactory, modes of patient management. Ask yourself: What am I doing in my practice, and why am I doing it?

The next step is to open our minds to the idea of change. Our value lies in our analytical skills and our ability to synthesize information, not in being storehouses of facts. We need to work hard to cultivate the talent to question all things, especially our own knowledge.

Once our minds are open, we need to listen. We have to hear what patients are saying between the lines. We have to take the letters from insurance carriers concerning prescribing or referral habits out of the trash and see what they have to say. Find out what is behind their pronouncements, not for argument’s sake, but to analyze and understand the information.

Many of us get defensive when we realize that our practice habits can be improved. We are not used to nonsuccess of any sort. We get embarrassed, feel threatened and then guilty. Anything short of perceived perfection is threatening. Information mastery means realizing there is much we do not know. The first step to knowledge is the confession of ignorance. We need to look for ways to become free of self-deception (take off the rose-colored glasses) by looking beyond the dogma.

Determine Patient-Oriented Outcomes of Importance

There are many questions that have not been answered by the science of medicine. We know much less about the optimal care of patients than most of us care to confess.

Information masters know that there is much work to be done to shore up the science that supports medicine. Recent studies have shown that only approximately half of the best clinical information is based on good evidence. For example, the latest anticoagulation guidelines were developed using the highest quality evidence only 44% of the time.

Nonetheless, everyone needs to figure out the patient-oriented outcomes of importance to their patients. Start with the concept that patients want to live long healthy symptom-free productive lives. What are you willing to do to meet this goal? Independent thinking is a necessary requirement for exploration of new ideas.

Develop Information Skills

There are several skills necessary for becoming an effective information manager. All of us need to develop quick ways of identifying new information and evaluating its validity. We can begin by being discriminating in our sources of information, since the easiest source may not be the best.

Hunt and forage. Most of us seek information in 2 ways. Sometimes we hunt, searching for information to answer specific questions. To hunt for information, we need to assemble sources that will allow us to find what we need in the least amount of time. Some computerized sources of information are designed to lead us to well-validated, predigested information within 1 minute of starting. InfoRetriever, The Cochrane Database of Systematic Reviews, and Best Evidence, are CD-based databases that provide validated information in an easily searchable format.* In addition, various Internet sites are available that give access to valid, predigested information, including this journal’s POEMs online (www.infopoems.com), Bandolier (www.jr2.ox.ac.uk/Bandolier), Dr’s Desk (drsdesk.sghms.ac.uk), the TRIP database (www.ceres.uwcm.ac.uk), and DynaMed (www.dynamicmedical.com).

At other times we forage; rummaging for new information. To stay up to date, it is necessary to develop an information-gathering plan. This is not as onerous as it sounds. We can use POEM bulletin boards to keep on top of new information. These sources, such as Evidence-Based Practice, Evidence-Based Medicine, and ACP Journal Club, use specific criteria to identify and present the results of studies that investigate patient-oriented outcomes.

We need to forage and hunt to keep up to date and to find information as necessary. Without both, you do not know what you are looking for and cannot find it when you do.

Use YODAs. In the Star Wars mythology, Yoda is a mentor who provides guidance and interpretation. In a previous paper we defined a YODA—Your Own Data Analyzer—as a person or source of information that can take the best information available, analyze it to determine whether it is valid, and interpret it within the context of clinical practice. In medical practice, we need to identify our own YODAs and also be one for others.

A YODA can be a colleague or someone in the community who has demonstrated an understanding of evidence-based medicine. We need to identify our YODAs, and ask them regularly for their thoughts on issues we confront in practice. Do not rely solely on their pronouncements, however; ask them to identify the evidence supporting their assertions.

An alternative to local YODAs are published YODAs, such as The Cochrane Library a database of meta-analyses, or the POEMs column and the evidence-based reviews in The Journal of Family Practice. Both the Journal’s evidence-based reviews section and the Cochrane database start with a clinical question and employ all of the valid research literature on the topic to formulate an answer based on the best available evidence. The Cochrane database is available on compact disk or at the Cochrane Collaboration’s Web site (www.updateusa.com/clibip/clib.htm).

In addition to identifying YODAs, we should strive to become one. No one can be an expert on everything in medicine, but we can all become one on a few topics that we find especially interesting. For those topics, know the literature. Become a resource. Once we have developed the confidence in our own YODA-hood, we can be one for others. Our positive influence on our colleagues will help them and their patients.

Be discriminating in CME participation. Choose your continuing medical education (CME) time carefully. The research is quite clear: Most people retain very little information presented at CME conferences. Two options present themselves: (1) pick useful CME; or (2) use the opportunity as an excuse to go to a fun locale. If you decide on the first option, work to identify CME opportunities that use interactive formats, such as workshops during which YODAs present evidence that can be evaluated for validity. Not all evidence-based medicine CME conferences meet this criterion.

Whether listening to a speaker or talking with a colleague or consultant, keep in mind the golden question: “That’s interesting … what evidence supports that idea?” There are hundreds of ways to ask that question diplomatically. It is not a judgment or an accusation, but simply a way to further understand the strength of a recommendation or clinical practice. If it is not a valid POEM, it is not necessarily useful information.

You may also need to spend some time tracking down the information supporting the speaker’s conclusions. Speakers may not have that information at their fingertips but they may be able to point you in the right direction. Always write down your questions for follow-up later.

Learn by doing. We learn best by doing. Consider setting up a practice-based small-group CME.³³ Set aside time each month to work with colleagues to answer clinical questions. Decide on a clinical question, find information to answer it, and use the monthly meeting time to present and discuss the information with others in the group.

The development of practice protocols or guidelines is an easy outgrowth of this type of CME activity. Many opportunities exist to get involved in local guideline or protocol development at your hospital or managed care organization. Use the opportunity to learn and teach. Guidelines have their greatest impact on those who are instrumental in developing them.

Finally, we should teach our pharmaceutical representatives to bring us POEMs. Tell them that physicians do not have time for interesting but irrelevant information; we want evidence that shows their product is safer, more tolerable, more effective, less expensive, or simpler to use than the alternatives. Do not let them schedule reminder appointments; tell them we do not want to see them unless their information is new and important to our patients.³⁴

Make the Change a Part of Practice

We are not finished once we have simply decided to change. We have to make the change part of our practice routine. Our subconscious tendency is to resist change—especially large changes. Doing something differently requires more than good intentions.

We should start by sharing what we have learned with others. One of the best ways to learn something is to teach it to others. (As we noted in a previous article, the only one who really learns anything from a CME presentation is the presenter.²)

Another method of incorporating change is to break down the barriers to change by getting everyone on the same team. Relationships within a medical practice (or in a medical community) can be parasitic, competitive, or complementary. Medical offices staffed by personnel with parasitic relationships do not succeed because they destroy the practice from within. Competitive relationships within a practice—pitting physicians against one another or professional staff against administrative staff—drain energy from everyone. Complementary relationships in a practice, however, overcome barriers, foster an atmosphere of teamwork, and most important, allow everyone to teach everyone else. In one of our offices, the expert source of vaccine-related information is not an physician or a pharmacist, but a nurse who can quote dosing information and Centers for Disease Control recommendations. She regularly updates the staff on vaccination issues.

Another idea is to change processes rather than ourselves. Some behaviors can not change until we change the underlying structure of practice.³⁵ This is a central concept of continuous quality improvement. For example, if we decide to let men make their own decision regarding prostate cancer screening, we must make sure that patient information sheets about the test are within easy reach. And instead of having to remember to examine the feet of every patient with diabetes at each visit as outlined in recent guidelines, we can institute a policy in which all of these patients are instructed to take off their shoes and socks at each visit.

Everyone in the office can be involved in process change. Involve all of the staff, from the nurses to the administration staff, in identifying patients who need a flu shot or who are still smoking, so one person does not have to remember it all. Be goal oriented. Keep the big picture in mind. Set the boat’s destination, and let everyone help do the rowing.

Conclusions

Change before you have to.

Change begins with a questioning mind searching for new and better information. The development of the skills necessary to find and evaluate information should follow. And implementing the changes of ingrained habits is the final and most difficult part of the process.

Evidence that matters is information that requires a change in practice. Information mastery is necessary because of the core value of all health care: we strive to do what is best for patients. When presented with valid evidence that will improve the quality of care of our patients, we must accept the challenge and the responsibility of changing our behavior and implementing those changes in our practices.

One of the greatest pains to human nature is the pain of a new idea.

Medicine, like most professions, is in danger from a tsunami created by the information explosion of the 1990s. This tidal wave of information, as well as its push-button accessibility, is threatening the basic foundations of the profession. The clinician is no longer considered the exclusive interpreter of medical wisdom and the sole arbiter of what is best for patients. Government agencies, managed care organizations, the news media, and advocacy groups all use medical information to influence patient care. All of these groups are constantly monitoring medical research to determine whether we are changing the way we practice when new and better information comes along.

In this article, we focus on how we learn from this information. From that perspective we will talk about how to change, since change is the ultimate goal of information use.

Why is change so important? The advent of new diagnostic tests, procedures, and medications make it necessary for us to change on a regular basis. Every clinician must change practice habits many times during a career. One can choose either to lead change or be dragged along behind it.

Our article is not about reacting to outside attempts to induce change, the carrots or sticks used by agencies and organizations to motivate us do something different. It is about truly being a master of information rather than its servant.

Information and change: How we learn

At the beginning of life, our minds are like empty shelves in a grocery store. As we learn, we stock them with units of information. Much of our lives are spent filling those shelves with the things we have learned.

Like bread in the grocery store, our information becomes stale and eventually expires. As we continue the lifelong learning process, we replace what has gone stale with fresh units of information. Unfortunately unlike the grocer’s shelves, the information gathered during medical school and in practice does not have an expiration date stamped on it. As a result, we may not know when our existing information has become stale or invalid. And similar to a loaf of stale bread, the information that we store can appear fresh, even though it is past its expiration date.

This lack of expiration labeling makes the job of the information master much more difficult. We need to search continually for new information to discover when our existing information has become outdated.

Think about the information that has become available in the last 10 years: antibiotics for treatment of peptic ulcer disease, the ineffectiveness and possible harm of patching corneal abrasions, therapy of deep venous thrombosis changing from 14 days of hospitalization to at-home treatment, and angiotensin-converting enzyme inhibitors and b-blockers used instead of digoxin as the cornerstone of heart failure therapy. To do what is best for patients, we need to identify new information and assimilate it into daily practice. Maintaining best practices requires change.

In our first paper, we distinguished “data” and “information” from the “knowledge” and “wisdom” that are the results of our brainpower. As a critical prerequisite to change, we must separate our view of ourselves from the information we have. Our value—to individual patients as well as society—is based on our ability to think using the information we accumulate.^11,12 Descartes said, “I think, therefore I am,” not “I know a lot, therefore I am.” We can only think best when we have the best information. Information is useless without reflection and questioning.

Too often we get so attached to hard-earned knowledge that we get defensive when it is challenged by new information. We might interpret evidence requiring us to change as an assault on the integrity of our previous education (and so, in some ways, an attack on our very being).

But information only affects our decisions: It does not change our ability to think. The correct decisions of 5, 10, or 20 years ago were based on the best information available at that time. New evidence, however, requires that we change the way we think about things.

Barriers to Change

Humans spend their lives resisting change.

The idea of change seems self-evident: If people want to change, they will. However, it is not that simple. Many smokers want to quit. Many overweight people want to become svelte. There is a large gulf between wanting to change a behavior and actually changing it.

Several barriers get in the way of this process of change. Fear, discomfort with ambiguity, guilt, and loss of control top the list of reasons for resistance to change. The Figure 1 illustrates some of the factors that have an impact on the process of change. Another barrier is a lack of awareness of information. Sometimes, even when information is found, it may not seem trustworthy. We may think that the information is flawed, that our patients are different from those in the study, or that the results are not applicable to a particular patient. Or we may be uncomfortable with straying from the pack. Fear of lawsuits, bowing to authority, and the “we’ve-never-done-it-that-way-before” syndrome can keep us from doing something new and different.

Changing Yourself

For most doctors, change is virtually a routine part of life…. The alternative to controlling the process of change is to be controlled by it, and in dramatic cases, to experience professional or personal collapse.

Taking control of learning requires the prerequisites outlined in the Table 1. The process of change has 5 steps: obtaining new information; deciding, based on that information, that a new approach may be better; deciding to use a new approach; implementing it; and confirming that this change is beneficial. Below are several ideas to make these steps easier.

Become a Reflective Clinician

The process of change begins with reflection in action: thinking about what you are doing while you are doing it. This introspection, often confused with clinical experience, allows you to identify, though not necessarily fix, those aspects of practice you feel uncertain about. The first requirement of change is the identification of tried-and-true, yet not wholly satisfactory, modes of patient management. Ask yourself: What am I doing in my practice, and why am I doing it?

The next step is to open our minds to the idea of change. Our value lies in our analytical skills and our ability to synthesize information, not in being storehouses of facts. We need to work hard to cultivate the talent to question all things, especially our own knowledge.

Once our minds are open, we need to listen. We have to hear what patients are saying between the lines. We have to take the letters from insurance carriers concerning prescribing or referral habits out of the trash and see what they have to say. Find out what is behind their pronouncements, not for argument’s sake, but to analyze and understand the information.

Many of us get defensive when we realize that our practice habits can be improved. We are not used to nonsuccess of any sort. We get embarrassed, feel threatened and then guilty. Anything short of perceived perfection is threatening. Information mastery means realizing there is much we do not know. The first step to knowledge is the confession of ignorance. We need to look for ways to become free of self-deception (take off the rose-colored glasses) by looking beyond the dogma.

Determine Patient-Oriented Outcomes of Importance

There are many questions that have not been answered by the science of medicine. We know much less about the optimal care of patients than most of us care to confess.

Information masters know that there is much work to be done to shore up the science that supports medicine. Recent studies have shown that only approximately half of the best clinical information is based on good evidence. For example, the latest anticoagulation guidelines were developed using the highest quality evidence only 44% of the time.

Nonetheless, everyone needs to figure out the patient-oriented outcomes of importance to their patients. Start with the concept that patients want to live long healthy symptom-free productive lives. What are you willing to do to meet this goal? Independent thinking is a necessary requirement for exploration of new ideas.

Develop Information Skills

There are several skills necessary for becoming an effective information manager. All of us need to develop quick ways of identifying new information and evaluating its validity. We can begin by being discriminating in our sources of information, since the easiest source may not be the best.

Hunt and forage. Most of us seek information in 2 ways. Sometimes we hunt, searching for information to answer specific questions. To hunt for information, we need to assemble sources that will allow us to find what we need in the least amount of time. Some computerized sources of information are designed to lead us to well-validated, predigested information within 1 minute of starting. InfoRetriever, The Cochrane Database of Systematic Reviews, and Best Evidence, are CD-based databases that provide validated information in an easily searchable format.* In addition, various Internet sites are available that give access to valid, predigested information, including this journal’s POEMs online (www.infopoems.com), Bandolier (www.jr2.ox.ac.uk/Bandolier), Dr’s Desk (drsdesk.sghms.ac.uk), the TRIP database (www.ceres.uwcm.ac.uk), and DynaMed (www.dynamicmedical.com).

At other times we forage; rummaging for new information. To stay up to date, it is necessary to develop an information-gathering plan. This is not as onerous as it sounds. We can use POEM bulletin boards to keep on top of new information. These sources, such as Evidence-Based Practice, Evidence-Based Medicine, and ACP Journal Club, use specific criteria to identify and present the results of studies that investigate patient-oriented outcomes.

We need to forage and hunt to keep up to date and to find information as necessary. Without both, you do not know what you are looking for and cannot find it when you do.

Use YODAs. In the Star Wars mythology, Yoda is a mentor who provides guidance and interpretation. In a previous paper we defined a YODA—Your Own Data Analyzer—as a person or source of information that can take the best information available, analyze it to determine whether it is valid, and interpret it within the context of clinical practice. In medical practice, we need to identify our own YODAs and also be one for others.

A YODA can be a colleague or someone in the community who has demonstrated an understanding of evidence-based medicine. We need to identify our YODAs, and ask them regularly for their thoughts on issues we confront in practice. Do not rely solely on their pronouncements, however; ask them to identify the evidence supporting their assertions.

An alternative to local YODAs are published YODAs, such as The Cochrane Library a database of meta-analyses, or the POEMs column and the evidence-based reviews in The Journal of Family Practice. Both the Journal’s evidence-based reviews section and the Cochrane database start with a clinical question and employ all of the valid research literature on the topic to formulate an answer based on the best available evidence. The Cochrane database is available on compact disk or at the Cochrane Collaboration’s Web site (www.updateusa.com/clibip/clib.htm).

In addition to identifying YODAs, we should strive to become one. No one can be an expert on everything in medicine, but we can all become one on a few topics that we find especially interesting. For those topics, know the literature. Become a resource. Once we have developed the confidence in our own YODA-hood, we can be one for others. Our positive influence on our colleagues will help them and their patients.

Be discriminating in CME participation. Choose your continuing medical education (CME) time carefully. The research is quite clear: Most people retain very little information presented at CME conferences. Two options present themselves: (1) pick useful CME; or (2) use the opportunity as an excuse to go to a fun locale. If you decide on the first option, work to identify CME opportunities that use interactive formats, such as workshops during which YODAs present evidence that can be evaluated for validity. Not all evidence-based medicine CME conferences meet this criterion.

Whether listening to a speaker or talking with a colleague or consultant, keep in mind the golden question: “That’s interesting … what evidence supports that idea?” There are hundreds of ways to ask that question diplomatically. It is not a judgment or an accusation, but simply a way to further understand the strength of a recommendation or clinical practice. If it is not a valid POEM, it is not necessarily useful information.

You may also need to spend some time tracking down the information supporting the speaker’s conclusions. Speakers may not have that information at their fingertips but they may be able to point you in the right direction. Always write down your questions for follow-up later.

Learn by doing. We learn best by doing. Consider setting up a practice-based small-group CME.³³ Set aside time each month to work with colleagues to answer clinical questions. Decide on a clinical question, find information to answer it, and use the monthly meeting time to present and discuss the information with others in the group.

The development of practice protocols or guidelines is an easy outgrowth of this type of CME activity. Many opportunities exist to get involved in local guideline or protocol development at your hospital or managed care organization. Use the opportunity to learn and teach. Guidelines have their greatest impact on those who are instrumental in developing them.

Finally, we should teach our pharmaceutical representatives to bring us POEMs. Tell them that physicians do not have time for interesting but irrelevant information; we want evidence that shows their product is safer, more tolerable, more effective, less expensive, or simpler to use than the alternatives. Do not let them schedule reminder appointments; tell them we do not want to see them unless their information is new and important to our patients.³⁴

Make the Change a Part of Practice

We are not finished once we have simply decided to change. We have to make the change part of our practice routine. Our subconscious tendency is to resist change—especially large changes. Doing something differently requires more than good intentions.

We should start by sharing what we have learned with others. One of the best ways to learn something is to teach it to others. (As we noted in a previous article, the only one who really learns anything from a CME presentation is the presenter.²)

Another method of incorporating change is to break down the barriers to change by getting everyone on the same team. Relationships within a medical practice (or in a medical community) can be parasitic, competitive, or complementary. Medical offices staffed by personnel with parasitic relationships do not succeed because they destroy the practice from within. Competitive relationships within a practice—pitting physicians against one another or professional staff against administrative staff—drain energy from everyone. Complementary relationships in a practice, however, overcome barriers, foster an atmosphere of teamwork, and most important, allow everyone to teach everyone else. In one of our offices, the expert source of vaccine-related information is not an physician or a pharmacist, but a nurse who can quote dosing information and Centers for Disease Control recommendations. She regularly updates the staff on vaccination issues.

Another idea is to change processes rather than ourselves. Some behaviors can not change until we change the underlying structure of practice.³⁵ This is a central concept of continuous quality improvement. For example, if we decide to let men make their own decision regarding prostate cancer screening, we must make sure that patient information sheets about the test are within easy reach. And instead of having to remember to examine the feet of every patient with diabetes at each visit as outlined in recent guidelines, we can institute a policy in which all of these patients are instructed to take off their shoes and socks at each visit.

Everyone in the office can be involved in process change. Involve all of the staff, from the nurses to the administration staff, in identifying patients who need a flu shot or who are still smoking, so one person does not have to remember it all. Be goal oriented. Keep the big picture in mind. Set the boat’s destination, and let everyone help do the rowing.

Conclusions

Change before you have to.

Change begins with a questioning mind searching for new and better information. The development of the skills necessary to find and evaluate information should follow. And implementing the changes of ingrained habits is the final and most difficult part of the process.

Evidence that matters is information that requires a change in practice. Information mastery is necessary because of the core value of all health care: we strive to do what is best for patients. When presented with valid evidence that will improve the quality of care of our patients, we must accept the challenge and the responsibility of changing our behavior and implementing those changes in our practices.