In Craig Fox and Noah Goldstein’s research, physicians respond to "top performer" label
Here's a message from the boss you'd likely remember for a long time, even if it arrived as a routine and private email: "You are not a top performer." For most conscientious professionals, "You are a top performer" would be memorable, too.
Some background: The power of emailed nomenclature such as this was highlighted last year in a Journal of the American Medical Association study about inappropriate antibiotic prescriptions, a chronic public health issue experts have struggled to contain. In the experiment, doctors all but stopped writing antibiotic prescriptions for illnesses that didn't require them after emails tagged them as top (or not top) performers in the fight.
The findings come from a team of seven researchers made up of medical doctors, social psychologists and behavioral economists, including UCLA Anderson's Craig Fox and Noah Goldstein. The team has published numerous studies in JAMA and elsewhere on strategies for reducing antibiotic overprescribing in primary care clinics.
Now, follow-up data show that these messages stuck. Recipients maintained improved prescribing practices in the year after the emails stopped, even as colleagues who improved under other interventions reverted in greater numbers to old habits. Other strategies cut rates of inappropriate prescriptions temporarily, but their effects faded before the year was up, as summarized by the authors in the October 10 Research Letter in JAMA.
The findings are the team's latest in a series of studies seeking to reduce antibiotic overuse in primary care facilities, a chronic problem that contributes to millions of illnesses and deaths every year, according to the Centers for Disease Control and Prevention. Antibiotics taken for nonbacterial infections, such as most acute respiratory illnesses, provide no benefits to patients. But they can cause serious side effects, and overuse enables the rise of deadly, antibiotic-resistant infections, according to the CDC. About half of antibiotic prescriptions from U.S. outpatient clinics are unnecessary, the agency estimates.
Fox and colleagues look for low-touch behavioral interventions, or "nudges," that push individual doctors, nurses and other prescribers to back off from antibiotic use. With experiments based in behavioral economics and social psychology, their strategies recognize that the human need for social approval often trumps rational decision making, even among highly educated individuals.
The team has documented, in JAMA studies and elsewhere, strategies that help the cause. Poster-sized letters committing a clinic to responsible antibiotic stewardship and featuring clinician photos and signatures reduced the problem by about 20 percent, according to one of their early studies. Popping up alternatives to antibiotics on the electronic records screen as doctors were making a record of the patient visit also cut down overuse. Requiring the doctor to write an explanation for a diagnosis-inappropriate prescription had promising effects.
But nothing worked nearly as well, or for as long, as the emailed rankings.
You Are Writing Too Many Unnecessary Prescriptions
In the 2016 JAMA paper, the team studied the prescribing habits of 248 clinicians (such as doctors and nurse practitioners) at 47 primary care practices in Los Angeles and Boston. They focused on antibiotic prescription rates across 17,000 cases in which the clinician diagnosed acute respiratory illness, which does not warrant antibiotics. For the first 18 months, the researchers simply tracked prescribing habits. Then, between November 1, 2011, and October 1, 2012, they employed several intervention strategies and continued to document.
In the "peer comparison" experiment, each clinician received a monthly tally of his unwarranted antibiotic prescriptions. Those with the lowest rates of inappropriate prescriptions were congratulated for being top performers. Those with higher rates were told, "You are writing too many unnecessary prescriptions" and "You are not a top performer." They were shown their rates of inappropriate prescribing against the typical rate for a top performer in the practice. They were given a link to prescribing guidelines and asked to review.
Inappropriate prescribing in the peer comparison experiment dropped from 19.9 percent to 3.7 percent by the end of the original study. Moreover, the ranking strategy appears to have ingrained better habits in a way that other efforts didn't, according to follow-up results.
A year after the emails stopped, the peer comparison clinicians were the only professionals to maintain a statistically significant difference in inappropriate prescribing rates from the control group, according to the latest findings. The group's rate of inappropriate antibiotic prescriptions went from 19.9 percent before any intervention to 3.7 percent when the interventions were stopped. In the follow-up study for the year after ratings ended, their rates of poor prescribing ticked up to 6.3 percent from 4.8 percent. (Rates are different at the end of the original study and beginning of the follow-up because some clinicians did not participate in the latter.)
Notably, the clinicians did not appear to change their diagnoses during the experiment in order to justify antibiotic prescriptions, according to the researchers. They simply wrote fewer antibiotic prescriptions.
The Power of a Gold Star
Seemingly obvious approaches for changing clinicians' prescribing habits have not solved the problem of antibiotics overuse. Educating doctors on antibiotic protocols isn't particularly helpful, UCLA Anderson's Fox explains in an interview, because they already know the protocols. Pop-up reminders of antibiotic prescribing guidelines are considered annoyances for the same reason, and clinicians tend to click right through them. Prescribers haven't responded to monetary incentives.
The problem with each of these interventions is that they assume that physicians are self-interested rational agents. But in human behavior, social motivations often override rationality, Fox explains. Moreover, clinicians' reasons for overprescribing are likely to be social, rather than a belief that the antibiotic is needed, he says. Maybe the doctor wants to placate a patient who might otherwise complain to the doctor's supervisor or give him a bad review online. Or maybe he fears making a decision that will be exposed as wrong if the patient returns.
"In my experience, doctors are human and kind of a competitive lot, and they respond to social interventions," says Fox. Like everyone else, he says, doctors want to fit in with their peers.
Fox believes this desire for collegial acceptance drives the positive results from the peer comparison intervention. While a doctor might see his own inappropriate prescriptions as insignificant, the emails put his actions into perspective with colleagues in a unified fight against over-prescribing.