Few could argue providers' role in two of the leading public health concerns facing the country; the opioid epidemic and the threat posed by infections that are resistant to antibiotics.
Both problems can be traced back partly to clinical decisions that led to overprescribing pain relievers or antibiotics. Experts say those decisions can be influenced by peer pressure or the desire to fit in—the same factors that affect the average person's decisionmaking abilities.
"It creates a tension in our mind because we think of doctors as experts," said Jason Doctor, chair of the health policy and management department at the University of Southern California, Los Angeles. "But there is a difference between being an expert in understanding clinical facts and understanding how to make the best decisions."
Doctor co-authored a JAMA study published this week. He said that study presents a huge opportunity to fully examine the causal role social factors can play in clinical decisions. And that, Doctor said, could be key toward improving clinician prescribing habits and by proxy, combating the opioid epidemic and improving antimicrobial stewardship.
"In the past, we have thought of physicians as these sort of rational agents where all we had to do is just educate and remind them about prescribing guidelines and they would do well," Doctor said. "That really has not worked."
He said research has begun to look at other factors that might influence physician decisions, such as the desire to preserve or enhance their professional self-image, or anxiety over how they rate among their peers.
The study is a follow-up to an analysis published last year that looked at the effect of interventions given to clinicians in Boston and L.A. to lower inappropriate antibiotic prescribing when treating acute respiratory infections, a practice the Centers for Disease Control and Prevention has estimated makes up about 44% of all outpatient antibiotics prescriptions while they are only necessary in about half of those cases.
That analysis found antibiotic prescribing rates decreased over an 18-month study period with the use of three interventions. One included suggesting non-antibiotic alternatives through electronic health records. Another required physicians to justify why they prescribed antibiotics. The third intervention sent monthly emails to clinicians that compared the rate at which they inappropriately prescribed antibiotics with their peers.
Rates of inappropriate prescribing fell lowest among those clinicians required to justify their decisions, as well as among those who got peer comparisons.
In the latest study, the interventions were stopped and clinicians were then monitored over 12 months to see if their inappropriate antibiotic prescribing rose again. Inappropriate prescribing of antibiotics increased among all study groups after a year, but remained lowest among those in the peer comparison group at 6.3%.
Interestingly, the rate of inappropriate antibiotic prescribing went down even among clinicians in a control group who received no interventions at all but were simply told they were being monitored. Past evidence has shown doctors appear to perform better at times when they know they are being watched.
A May study in JAMA Internal Medicine found hospitals that admitted Medicare patients during a week when the Joint Commission was conducting an inspection of the facility had a 6% decrease in their 30-day mortality rates compared to weeks when they were not being surveyed.
According to study co-author Dr. Jeffrey Linder, the findings suggest institutions might look into using interventions on a long-term basis as a means of influencing clinician decisionmaking.
"Doctors are people too and we want to be liked by people, and we want to do well relative to our colleagues," said Linder, a professor of medicine and chief of the division of general internal medicine and geriatrics at Northwestern University's Feinberg School of Medicine. "Why shouldn't doctors respond to the same sort of peer comparisons and social norms that everyone does."
