I fear change, I will keep my bushes: EBM, email & human nature

My husband just made fun of me for trying to find a Quizno's commercial from the turn of the century without success.

(May 12, 2009 edit: Bless you Xyc0, you have FOUND THE VIDEO!!)

Perhaps you remember it. The opening dialog is between two three primitively dressed British actors (and another standing around) at a ranch on the outskirts of Los Angeles (no, really), one wearing pants with the others holding on to what looks like a tumbleweed for apparel, and they meet and greet one another...

Primitive Brit 1: Aah! You are cursed with the legs of a goat!

Primitive Brit 2: Nay, these are pants! No more thorns and bugs!

Primitive Brit 1: I'd like to wear pants!

Primitive Brit 3: I fear change, and I will keep my bushes.

The part about hanging on to the tumbleweed because of fearing change has been on my mind today. I have read, re-read and am still pondering a blog entry from yesterday that caught my attention via Kevin MD about evidence-based medicine (EBM) and the difficulty in persuading physicians to change their practice. I cannot summarize the historical background quickly so please give it a read if you're curious about how long it took between the first randomized control trial (RCT) & setting best practice standards (hint: 1 century is about halfway there) and while we may promote EBM to resistant audiences, we're unlikely to die in a 19th century insane asylum in part due to physician resistance to installing plumbing for handwashing (RIP Dr. Semmelweis, we're still fighting ventilator-associated pneumonia (VAP) and Methicillin-resistant Staphylococcus aureus (MRSA) over the same thing).

What really got my attention was this section, based in part on Asch SM, Kerr EA, Keesy J et al., Who is at greatest risk for receiving poor quality health care? New England Journal of Medicine, 2006 Mar 16;354(11):1147-56.

"The gap between what we know works and what is actually done is substantial enough to warrant attention," the NEJM study concluded.

"What can we do to break through this impasse?" the researchers asked. "Given the complexity and diversity of the health care system, there will be no simple solution. A key component of any solution, however, is...to make information available...with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality." In other words, we desperately need electronic medical records, and the data from those records needs to be consolidated in order to establish benchmarks for performance and best practice guidelines.

But even the best healthcare information technology will not help if physicians resist the fact that medical knowledge is constantly changing, Lalvani points out. Too often, physicians stick to the treatments they have always used, declaring that if tens of thousands of physicians do it this way, it must work.

I'm not certain I would agree with the author's inclusion of "we desperately need electronic medical records" (EMRs) because without careful user needs assessment, research, integration & training EMRs can backfire just as easily as whatever the latest 'ooh!' technology toy du jour does. There is not currently and I doubt there can be a one-size-fits-all EMR (we won't even touch the hot potato clinical decision support systems (CDSS) part of the equation!) as long as we have so many different key players in the health care industry.

Resistance to change, however, is an undeniable part of human nature that is most successfully overcome through extreme patience, persistence and education in conjunction with assessing user information needs (before, during & after) to determine the proposed changes will/are actually work(ing). In our MLA class we had an episode last week where, despite being instructed to post blog entries or contact our online instructors via chat with gentle reminders along the way, there was an outbreak of using an email listserv to communicate participant thoughts regarding the class. The listserv manager finally limited postings to instructors because the emails were becoming way too numerous.

I find this fascinating: we, as medical librarians and agents of change (I need a badge), in a class specifically for learning about new online communication technologies... went straight back to the familiar standard email listserv without hesitation even when we were told not to do so from the beginning.

Wow. Talk about fearing those goat legs and hanging onto the tumbleweeds in the face of change! I hope the class remembers this listserv stint when we experience difficulty in reaching/teaching our users regarding EBM (and other changes) though. We have great curriculum sources such as the EBM Librarian Wiki, but it takes time and knowledge of your users to teach new ways of practice. I think this is especially true when it comes to students who are learning from clinicians who have 'always done it this way.' If there's too much, too fast or any semblance 'you're doing it wrong' as part of the instruction to a group of people who are given a high level of societal power... well, it's not exactly surprising that hospital libraries are closing because they aren't perceived as valuable, is it? At least they haven't carted the librarians off to the insane asylum (yet)!