Details for doctors
AS THE Commonwealth struggles to improve the quality and contain the costs of our unwieldy health care system, we need to pay more attention to the one fulcrum around which most health care decisions (and therefore expenses) pivot: what doctors know. We physicians don’t wake up in the morning planning to make bad drug-use decisions or order unnecessary tests. It is just that it’s no one’s job to help us find the information we need to make the best choices for our patients.
Thousands of research papers appear each month in the biomedical literature, and hundreds are directly relevant to clinical choices from depression to diabetes. But there is no systematic way of filtering that knowledge and transmitting the findings to physicians.
This challenge of communicating science to practitioners is not unique to medicine. For generations, farmers found it hard to keep up with important discoveries in crop science, fertilizers, and irrigation because they had no reliable way of learning about them. So, in the early 20th century, Congress created the Agricultural Extension Service, which paid workers to travel from one isolated farm to another, bringing news of the latest findings on farming.
Today’s primary care doctor has a lot in common with the farmer of yesteryear. Many labor in isolation or in small groups, and it is no one’s job to provide them with unbiased reports of medical advances or risks of the products they prescribe. The problem of poor information flow contributes to runaway health budgets and suboptimal quality of care. For news about medications, the only people reaching out effectively to doctors have been the sales representatives of Big Pharma, known as detailers, who are paid to increase sales of the costliest products.
As a medical student many years ago, I wondered whether the Agricultural Extension Service model might be applied to the health care system. I developed the concept of “academic detailing,’’ in which university-based faculty assemble balanced overviews of the latest findings on how best to treat a particular clinical problem, and then train “un-sales reps’’ to bring those recommendations to doctors.
Learning much from the drug industry, we used a marketing-like approach, hiring and training pharmacists or nurses to visit doctors in their offices and teach them interactively. It worked. Several of us now collaborate with the non-profit Independent Drug Information Service, which makes available evidence-based modules on over a dozen common prescribing problems. None of us accepts compensation from pharmaceutical companies. In several states, government funds academic detailers, and a cost-effectiveness analysis found that such programs can save two dollars for every dollar they cost to operate.
Public service programs based on this model have now been established by several states, HMOs, the Veterans Affairs health care system, and a number of national governments. A pilot program was written into the Massachusetts legislation that established our near-universal coverage plan, but it has been progressively de-funded in the last few years and, if funding is not extended, is likely to end this summer. It would make sense for a consortium of insurers to fill this funding void, but such help is not in sight. As other state and national governments embrace academic detailing, the state where it all began seems ready to give up on bringing physicians the best evidence to guide our decision-making.
Dr. Jerry Avorn, a professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, is author of “Powerful Medicines: the Benefits, Risks and Costs of Prescription Drugs.’’