Sometimes Doctors Need to Be Nudged

Richard M. Plotzker, MD


April 17, 2018

We doctors and other providers have lots of things that we ought to do for patients—things we intend to do, try to do. But when the audit of what we actually did is performed, our perception of our thoroughness sometimes exceeds what the record indicates actually happened.

Richard M. Plotzker, MD

For a number of years, I have served as a commentator on diabetes audits for a large insurer. The company sends me data from the local division and sometimes comparable data from their other divisions around the country, along with the minutes of their diabetes committee's discussions about how to engage patients more in getting their eyes examined, and how to get doctors to take a more aggressive approach when patients' A1c, cholesterol, and blood pressure measures are above target.

Everyone means well, works diligently, and wants patients to benefit from their doctors' skills, without putting too much blame on patients for noncompliance.

Yet, after doing these reviews for this long, I have noticed that the percentage of overdue eye exams in our Medicaid population improved by only a small amount, the fraction of patients whose A1c levels weren't checked in a year remained the same, and LDL-C levels over 100 mg/dL never improved much despite the relative ease of accomplishing this in most people.

Moreover, when they sent me the comparable data from Nebraska, which has a rural population and where doctors are sometimes in short supply, and from the District of Columbia, which has an urban population with a high physician density—as well as a few other geographic areas—I saw little variation in these performance trends.

The solution may be to offer the electronic version of a string around the finger.

At the same time that there seems to be a shortfall on needed care, there is sometimes excessive care that wasn't needed to begin with. On most days, the glucose test strip renewal requests come through the fax machine in a short stack, and many faxes are prepopulated with authorizations for various topical analgesics that few people need. Often, the forms use an opt-out system, and it's difficult to get the electronic form-filler to draw a blue X through the box, let alone to remember to do it.

So Medicaid pays less to the ophthalmologists than they budgeted for eye exams but more to pharmacies for various Atomic Balms.

In the exam room, the provider's focus is on questioning patients about their fingerstick log or looking between the toes for tinea pedis. Remembering the flu shot at the autumn visit may not happen. Similarly, it is easy to mark a lipid panel on the lab authorization, but it's a lot harder to pay attention to whether the lab ever reported a value.

The solution may be to offer the electronic version of a string around the finger that reminds people of their overlooked tasks without conveying an impression of being improperly manipulated.

The Leonard Davis Institute of the University of Pennsylvania recently reported on a system they call Nudges, implemented by a dedicated Nudge Unit, to try to modify physician decision-making without becoming a noodge.

They looked primarily at restructuring the order sets of the electronic medical record to achieve desired, noncontroversial outcomes, from selecting less expensive but equally efficacious medicines, sending myocardial infarction (MI) patients to cardiac rehab in a more consistent way, getting more patients vaccinated for the flu, and helping physicians be more purposeful in selecting expensive lab testing.

Some of the changes seemed pretty straightforward, like listing the menu of medicines by cost rather than alphabetically, or defaulting patients with a recent MI to rehab registration unless the doctor opts out, much like we encounter with those topical analgesics for patients with diabetes. Some of the nudges required a little more sophistication, such as moving the checklist for influenza vaccination from the busy physician who is focused on other things to a supporting nonphysician staff member.

The researchers who developed the Nudge system basically found that doctors function partly the way medical school graduates do and partly the way consumers do. This is not surprising, as we are all familiar with the model where you order a hat and are asked if you want to order gloves, too.

The medical analog differs not so much by process but by purpose, having the patient rather than a commercial enterprise as the beneficiary even though the doctor really functions as the intermediary. People choose from the top of their menu, so drugs that start with A have an advantage over drugs that start with W—until you sort by price, which leaves the attention of the prescriber at the top of the list but the medicine selected will be less expensive.

When prices of diagnostic tests were included in the order menu, doctors acted like consumers. As they became aware of what intricate genetic testing costs, they got more selective about ordering it, but they also learned where the bargains are.

For $11 you can never go wrong with a basic metabolic panel, so they ordered more of the economical tests, much like a consumer would stock up on something that he perceives to be on sale.

Of course, there can always be too much of a good thing, with some nudges morphing into noodges in the form of endless, disruptive pop-up reminders. Those got deleted quickly by the physician consumers, much like we do to Internet pop-ups, even though the reminders might be of great patient value.

Ultimately, nothing really gets implemented in patient care unless the provider orders it. Popular drugs become popular by proving themselves beneficial, and mainstream diagnostic testing gets that way by physicians perceiving its value and remembering to follow the algorithm; we choose the conferences that we attend because we understand their value.

Unfortunately, the menu of what we could do on behalf of patients far exceeds the realities of daily practice, as any number of implementation audits attest. We just have a limited radar and do not always keep what is most essential in our professional line of sight.

But the study from the Leonard Davis Institute offers some intriguing insight on how to alter physician awareness with no ulterior motive other than to get us to do what we should have been doing without that external prompt.


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