Author Affiliation: Office of the Dean, Faculty of Medicine, University of Toronto, Toronto, Ontario.
Better decision making by physicians could materially improve the balance
of benefits and harms in health care while saving billions of dollars. It
is therefore little wonder that academics, policy makers, third-party payers,
and leaders of the profession alike have been grappling for many years with
the challenge of modifying physician behaviors.
Conventional wisdom on that issue has arguably evolved through 4 phases.1 The Era of Optimism featured
a belief that physicians could be transformed into critical appraisal machines,
tirelessly combing the peer-reviewed literature and consistently translating
the best evidence about drugs and devices into action. The Era of Innocence Lost and Regained saw a loss of faith in passive diffusion
of evidence and its distillation by individual clinicians. Instead, the medical
establishment fervently embraced active dissemination and collective synthesis
of evidence in the form of meta-analyses, decision analyses, and practice
guidelines. The Era of Industrialization followed
once research studies showed that practice guidelines were not consistently
guiding practice. Physician-leaders and health care administrators borrowed
the ideas of industrial quality gurus; local implementation, under an alphabet
soup of rubrics, including CQI (continuous quality improvement), TQM (total
quality management), and Six Sigma, was the rage. The most recent phase seems
to be the Era of Information Technology and Systems Engineering. Using concepts from all 3 earlier phases, today's sociomedical engineers
attack systematic barriers to change, align economic and noneconomic incentives,
and deploy information tools to steer clinicians and all other involved decision
makers, including patients.
Naylor CD. The Complex World of Prescribing Behavior. JAMA. 2004;291(1):104-106. doi:10.1001/jama.291.1.104