How JeffCare changed its physicians’ behavior
A different approach to physician education
Medical groups use many methods to educate physicians about guidelines and protocols and to encourage their use. But those strategies aren’t always successful.
A systematic review of literature found proven success with reminders, patient-directed interventions, and educational interventions that included opinion leaders and one-on-one visits to physicians.1 Without linking them to other strategies, traditional continuing medical education conferences had little impact.
JeffCare, the physician-hospital organization for Thomas Jefferson University Hospital in Philadelphia, took those findings to heart and used them to shape a program of influencing physician behavior. Here are some of the strategies it uses:
• Primary care physicians receive one-on-one preceptorships with specialists.
Instead of attending didactic sessions, physicians learn from experts while they are tending to their own patients, says Jeffrey Lenow, MD, JD, the medical director of JeffCare and chairman of the disease management committee for Jefferson Health System.
For example, primary care physicians may schedule appointments for several diabetic patients back-to-back on a particular morning. "We’ll have one of our specialists come out and spend time with [these doctors] while they’re seeing patients," says Lenow.
"It’s a different approach to education," he says. "It’s part of what we call our physician-champion model. If you can influence key decision makers, they will disseminate good practices and ultimately you’ll be able to reduce variation."
Both the specialist and primary care physician receive a token compensation for their time in the preceptorship, but Lenow notes that the money isn’t of primary importance to them. The program has other ancillary benefits. "It’s a way for our specialists to get out and meet our primary care doctors, and relationships can develop that wouldn’t have otherwise," he says.
• Educational programs are interactive and problem-oriented.
Sometimes it’s best for physicians to share information in a group setting. But JeffCare makes sure these sessions remain focused on the real-life problems of physicians and how they can solve them.
For example, a half-day symposium for physician leaders gave them a forum for working through problems with improving compliance to guidelines and quality improvement goals. "We focused on problems related to evidence-based medicine and application to problems they specifically brought with them to the symposium," he says.
• Physician leaders share detailed data twice a year.
While data alone may capture a physician’s curiosity, he or she will have questions. Lenow spends much of his time visiting offices to discuss individual performance profiles and what they mean. "You’re only as good as your data and you’re ability to explain it in a user-friendly way," he says.
For some disease-management programs, teams of nurses pull every patient’s chart and use the data both for benchmarking and drafting specific suggestions for intervention. One site targeted 65 pediatric asthmatics in a Medicaid population. Nurses designed classes for parents, home visits, and family counseling to help them manage the asthma.
"With eight months of physician training and focused intervention and patient outreach, [the asthma patients] reduced their [emergency department] admissions by 80% and missed days from school by 60%," he says. "It’s not that a lot of physicians don’t know what to do. They’re not organized enough. They’re not getting enough help identifying the patients at need, and things start falling through the cracks."
• Guidelines are provided in a simple format that is easy to use in clinical practice.
Guidelines that are wordy and difficult to read simply won’t be effective, Lenow says. JeffCare reworks guidelines to place them in a format that provides true guidance to a busy primary care physician. "You can just narrow the choices of therapy or show a physician the 11 things that need to be done with a diabetic on a regular basis," he says. "They’re straightforward. All we’re looking for is support measures. We’re looking to reduce clinical variation."
• Physician leaders influence their peers on targeted clinical issues.
If you want change, start at the top. A study of physician leadership found that their strong support of a certain protocol, such as beta blocker use after a heart attack, could improve adherence.2 "The best practices out there need to be disseminated by the people who have the most influence," says Lenow. "That is a very key strategy for modifying physician behavior."
References
1. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: A systematic review of the effect of continuing medical education strategies. JAMA 1995; 274:700-705.
2. Soumerai SB, McLaughlin TJ, Gurwitz JH, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA 1998; 279:1,358-1,363.
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