BMJ  2004;329:1473-1474 (18 December), doi:10.1136/bmj.329.7480.1473

Experts' eye view

Easy ways to resist change in medicine

¹ Department of Family Medicine and Community Health, Tufts University School of Medicine, 100 Hospital Road, Malden, MA 02148, USA, ² Department of Family Medicine, Box 800729, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA

These time honoured techniques will help doctors resist the forces that prevail on them to change their ways of taking care of patients

Numerous forces have been imposed on physicians to make them change their practice behaviours. Under the guise of "quality improvement," managed care organisations, accrediting bodies, and the government are meddling in medicine. Even continuing medical education, previously a form of intellectual entertainment or a forum for much needed sleep, has refocused its efforts towards improving the care of patients (figure).

 

Techniques to resist change

Techniques are available, however, that will allow doctors to practise unimpeded by new information that should induce change. To avoid succumbing to both the inner and outer forces prompting change, we offer the following techniques and methods.

Don't pay attention
Get so busy with your practice that you do not have the time to read, attend meetings, understand your own practice, or observe the practice of colleagues. Forget about Stephen Covey's seventh habit of "sharpening the saw."¹ Create your own habit of sawing harder and harder, with a dull saw.

Attack the data
When provided with new information that may require a change in practice:

• Firstly, diss the source. No one expects you really to believe information from sources outside your specialty or geographical area.
  
• Secondly, question the validity of the information. Every study or report contains some loophole in its fabric, however small, that can be snagged and used to unravel the validity of the whole study. Use the common logical ploy that holds that if any aspect of the study is imperfect, the entire study results must be wrong.
  
• Thirdly, question the applicability to your patients. Studies are done "out there" and can't possibly reflect the unique nature of your practice. This technique is especially useful when data from large studies contradict our impressions gleaned from personal experience with a few patients.
  

Levels of belief Class 0: Things I believe Class 0a: Things I believe despite the available data Class 1: Randomised controlled clinical trials that agree with what I believe Class 2: Other prospectively collected data Class 3: Expert opinion Class 4: Randomised controlled clinical trials that don't agree with what I believe Class 5: What you believe that I don't

Maintain absolute confidence
Remember all the smart professors you had and realise that everything you need to know to practise good medicine was taught in medical school. Instead of worrying about this newfangled "evidence based" medicine, stick with "belief based medicine" and organise your thoughts by using the criteria in the box.²

Follow the pack
Stay far back, waiting for all your colleagues to change before you (reluctantly) join them. Of course, if you practise skill #1 correctly, you will never know what your colleagues are doing.

Defer to experts
Be sure not to make any independent decisions. An expert is always available somewhere to support your death grip on the status quo.

Bring in the lawyers
A good defence against change is to assert that you will get sued if you start doing something new or quit an old, favourite practice.

Blame patients
Claim that you'd like to practise differently but patients won't like it. Everyone will understand why you still give monthly injections of vitamin B-12 for anaemia and antibiotics for colds if you tell them your patients don't want you to stop.

Show how much you've changed
Point to all the new drugs you use as a result of information solely provided by pharmaceutical representatives. After all, it's more important to feel up to date than to actually be up to date.

Pull rank
When a case manager calls, a nurse or pharmacist makes a suggestion, or a patient brings in information they've downloaded, make sure to ignore it. Be sure to say, "When did you get your medical degree?"

Simply refuse
When presented by threatening information, say what was muttered after a presentation for continuing medical education: "I wouldn't believe this information even if it were true."

Total control

Using these time honoured techniques will allow you to practise with the assurance that little thinking will be required that might distract you from the matter in hand—taking care of patients as you see fit—and will keep you in total control without any nagging feelings that there might be a better way to practise.

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Contributors: AFS wrote the first draft, which was then edited and expanded by DCS.

Competing interests: None declared.

References

1. Covey SR. Seven habits of highly effective people: powerful lessons in personal change. 1st ed. New York: Free Press, 1990.
2. Bleck TP. Alternatives to evidence based medicine: different rating scale could be used. BMJ 2000;321: 239.[Free Full Text]

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Kudos to David and Allne

Daniel L Sontheimer
bmj.com, 24 Dec 2004 [Full text]

Surely you jest.

Edward Thompson
bmj.com, 31 Dec 2004 [Full text]