Physician explanations for failing to comply with "best practices".

CONTEXT: Substantial effort has been devoted to improving physician compliance with evidence-based guidelines. OBJECTIVE: To explore physicians' reasons for not following so-called "best practices" in caring for patients with type 2 diabetes. DESIGN: Descriptive study of self-assessed compliance with five measures of performance. PARTICIPANTS: Eighty-five internists who volunteered to participate in a practice-based research network created to improve clinical practice. DATA COLLECTION: Physicians reviewed their own charts of patients with type 2 diabetes mellitus (1755 patient encounters) to assess compliance and offered open-ended comments concerning their reasons for not complying with "best practices." RESULTS: The physician volunteers reported not complying with the annual foot examination in 13% of encounters. A similar level of noncompliance was reported for the annual lipid profile (15%) and retinal examination (17%). Among the five measures examined, noncompliance was most common for screening urinalysis (26%) and screening microalbuminuria (46%). The physicians' open-ended comments suggested that physician oversight, patient nonadherence, and systems issues were common reasons for noncompliance. However, noncompliance also resulted from a conscious decision by the physician, as indicated by comments about patient age and comorbid illness or, with nephropathy screening, established renal disease or current therapy with angiotensin-converting enzyme inhibitors. CONCLUSIONS: Even among a self-selected group of physicians, noncompliance with best practices in diabetes is common. Although physician forgetfulness and external factors are frequently offered as reasons for noncompliance, it may also result from a conscious decision, as physicians may disagree about what constitutes "best practices."

Cognitive psychological studies of representation and use of clinical practice guidelines.

Clinical practice guidelines provide a means to enhance physician performance. This investigation was undertaken in an attempt to understand the nature of impact of guideline use on physician performance. We investigated the impact of (a) algorithmic-based and (b) text-based practice guidelines on clinical decision-making by physicians at varying levels of expertise. Data were collected using clinical scenarios and a think-aloud paradigm, both with (primed) and without (spontaneous) the use of the guidelines. The two guidelines used in the study were management of diabetes and screening for thyroid disease. The results show that guidelines were used as reminders for both experts and non-experts. Guidelines acted as an educational tool for non-experts by assisting in knowledge reorganization, particularly for the non-experts. Text and algorithmic guideline formats were both useful to physician performance depending on the purpose of use: solving clinical problems or learning. These results provide insights into how guidelines can be fine-tuned for different users and for different purposes. Empirical research, coupled with design principles from the cognitive sciences, can form an essential component of guideline design and development.

Internists' evaluation of guidelines: the IMCARE Practice Guidelines Network.

This paper presents the attitudes and experiences of one group of practicing internists, the IMCARE Practice Guidelines Network, with clinical practice guidelines. From its beginning the Network has enjoyed close ties to both the Agency for Health Care Policy and Research (AHCPR) and the Institute of Medicine (IOM) with their guideline mandates. The Network is a self-selected group of 471 internists and their subspecialty colleagues, dispersed throughout the U.S. Network member evaluations of draft clinical practice guidelines present a compelling case for the need for clarity of language and a more condensed guideline structure. As Network members' critique indicates, once published, guidelines have become communication tools.

Primary care as form or content?

This article advocates revisiting the notion of primary care to include these dimensions: the physician-patient relationship, the notion of principal care, and the patient as validating the primary care relationship. The quality of primary care rests squarely on these three characteristics. From a systems perspective, the quality of primary care encompasses more than the right assortment of clinical competencies; quality has to be grounded in and realized at the individual level where physician and patient meet and interact over time. The discussion thus rests on the assumption that primary care is a process of care rather than a collection of skills. This study was stimulated by two factors: the claim of subspecialists to at times provide primary care and L. H. Aiken et al.'s article on the contribution of specialists to primary care. The author of the present article surveyed 467 internists and subspecialists and asked if they equated principal care with general internal medicine (IM) care-a primary care competency. The percentage of IM in their practice was also surveyed. The 160 responses revealed that the percentage of subspecialist care to primary care was similar to that described in Aiken et al.'s article. The notion of principal care thus appears to better reflect the realities of clinical practice.