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.