Models of Changing Clinical Practice

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There are a number of conceptual models describing the processes that individuals and organizations go through as they change behavior. Not surprisingly, these models come from fields that are intimately familiar with trying to change knowledge and behavior: psychology, education, health promotion, and marketing. Understanding how to get people to write better, eat differently, stop smoking, or buy a brand of milk is not conceptually different than getting clinicians to treat myocardial infarctions or asthma correctly. Models for understanding behavioral change are important because they lead to strategies for changing behavior (Table 1). Although there is some overlap, it is useful to think of these models as falling into broad categories: educational, epidemiological, and marketing strategies (targeting an individual's internal factors) and behavioral, social, organizational, and coercive (targeting factors external to the individual).

Educational models are the ones physicians are most familiar with. Adult learning theory stresses the importance of interactive educational experiences over passive learning in lectures. Examples include Advanced Cardiac Life Support or Advance Trauma Life Support courses taught with individual skill stations [8]. Epidemiological models focus on synthesizing and presenting the evidence on optimal practice. Examples include published meta-analyses, the Cochrane reviews, and formal guideline developing activities. Large data warehouses of these resources are available on the internet [9,10]. Marketing strategies rely on research to understand the values, concerns, aspirations, needs, and knowledge of their target audience [11]. Marketers realize that selling a product often does not rely on informing their audience about its benefits, but in convincing the target that they will be more popular if they buy it or 'left out' if they don't. Similarly, social marketers, trying to 'sell smoking cessation or appropriate antibiotic use must provide the audience with a reason to act that may have little to do with the evidence about benefits of the action.

A number of models try to influence behavior by using external factors to influence behavior. Behavioral theory uses feedback and stimulus-response to affect behavior such as automatic reminders or clinician audit and feedback reports. Social theory takes advantage of information about how individuals behave in groups. A model developed by Everett M. Rogers called the Diffusion-Adoption model has been used to study changes in use of hybrid seeds, computer technology, and magnetic resonance imaging [12]. Individuals fit into broad categories of: Innovators, Early Adopters, Early Majority, Late Majority, and Laggards based on their willingness to adopt new practices. Understanding which group a clinician fits into will let you understand the barriers to changing their practice. Organizational approaches are adapted from the Total Quality Management and other quality improvement methods used by corporations. The Institute of Healthcare Improvement (IHI) has championed these practices in healthcare [13]. Finally, coercive techniques rely on regulations, fiscal, or legal constraints or incentives to change practice.

There have been four recent extensive meta-reviews (reviews of reviews and meta-analyses) evaluating which techniques are most effective at changing clinical

Table 2. Evidence base for various behavior change strategies

Weak

Moderately

Relatively strong

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