Can Medical Decision-Making Keep Up With the Science?
On average, it takes 17 years for new treatments to reach mainstream clinical practice. That means that when patients see a doctor in 2020, they are often getting guidance from 2003. To put this into perspective, current practices come from a time before the iPhone! But during the pandemic, the speed of changes to medical decision-making rapidly accelerated. COVID-19 was a new, highly transmissible disease, and as data about the virus changed daily or weekly, so too did the care doctors provided on the frontlines. Case Study: The Speed of New Tests  COVID-19 testing provides an illustrative example of how fast medical practice changed during the pandemic. At first, only nasal PCR testing was available and it could only be administered by a healthcare professional. Within weeks, guidance was updated to allow patients to test themselves with a health professional present, such as at drive-thru test sites, and later, by themselves alone in the comfort of their own homes. Soon new tests became available, including saliva PCR testing and antibody and antigen tests. We also frequently received new information about specific manufacturers and tests. A 15-minute PCR test made by Abbott Laboratories was initially widely lauded, but weeks later, it was found to have a high false negative rate. In short, the medical science of COVID-19 testing was changing rapidly, but given the stress of the global crisis, medical practice largely kept pace. While COVID-19 provides an extreme case study of rapid medical advancement, it is only by a matter of degrees. About 2 million scientific articles are published each year, and new clinical guidelines are released every 1 to 3 years for every major disease. Add to that new FDA advisories and it leads to information overload. A few years ago, a common medication for high blood pressure was found to have a harmful contaminant, prompting a recall. Yet, months after that warning, I was still seeing new patients in my practice who were taking it. The pandemic highlighted the need for healthcare to be more responsive to changes in medical science and demonstrated that it's possible to do so. But the way we did so isn't scalable. We kept up with COVID-19 largely because it has dominated the headlines and discourse in medicine and in our everyday lives. But this won't work for the hundreds of conditions I manage in my practice each year. Instead, here are a few proven solutions to help physicians keep up with the pace of change and better support their patients:  Intelligent Clinical Decision Support  The electronic health record (EHR) system I use in my clinical practice is little more than an expensive collection of scanned paper charts. I document decisions in it after I make them -- the EHR doesn't help me make better decisions. Clinical decision support does exist in some forms but it's often not useful -- take, for example, pop-up alerts for potential drug interactions, which are generally no more than an unhelpful distraction. If we want faster adoption of new clinical guidelines, we need intelligent decision support embedded in the EHR. While typing in a patient's history, smart support should prompt additional questions to ask patients to ensure I take a complete history. For diagnoses, it should suggest alternate possible diagnoses to help me reduce misdiagnoses or limit the search of medications to those proven to be effective. Telementoring  It's not enough to have access to information on the latest medical science. In training, we learn by "see one, do one, teach one." Simply seeing a pop-up in our EHR, while helpful, won't be enough. In medicine, learning is a social process. One proven model for leveraging social learning once doctors get into clinical practice is telementoring, which is the brainchild of Sanjeev Arora, MD. As a liver specialist at an academic medical center in New Mexico, Arora saw patient after patient with complications of hepatitis C that may have been preventable had they been treated earlier. Knowing he couldn't treat every patient in the state with hepatitis C, he set up a hub-and-spoke system in which primary care physicians in the community presented cases weekly over live video conference to specialists at his academic medical center. This offered a way for them to learn on real patient cases how best to care for hepatitis C.  In a paper in the New England Journal of Medicine, Arora and colleagues proved that, with this experiential learning, these community doctors were able to manage hepatitis C as well as specialists. Physician Scorecards  By their nature, doctors are driven to self-improve, but we often don't because we lack trusted, objective data showing where improvement is actually needed. Surgeon-researcher Marty Makary, MD, MPH, Editor-in-Chief of MedPage Today, has pioneered a methodology for physicians to get such information. Using a national dataset, Makary sent hundreds of Mohs microsurgeons a letter with their performance on Mohs surgeries relative to their peers. Without sticks or carrots, the data alone changed physician behavior. Physicians who scored as outliers compared to their peers saw a remarkable 83% improvement in their practice. The key to the success of these physician scorecards was that they came from a peer, were objective, and weren't designed for payment or punishment but rather for learning. Taken together, these three innovations have the potential to dramatically accelerate the speed of innovation at the frontlines of care. It took a global pandemic for us to update our clinical practice more rapidly. Whether we sustain and scale these improvements is now up to us. Shantanu Nundy, MD, MBA, is a practicing primary care physician, the chief medical officer at Accolade, and author of Care After Covid: What the Pandemic Revealed is Broken in Healthcare and How to Reinvent It.