Turn to the evidence: working with physicians to make a change in clinical practice

At some point in the evolution of every antibiotic stewardship (ABS) committee, there comes a time for implementation: The roll-out of what committee members determine is the current best practice for ABS.

The problem—and what some now call “the 800-pound gorilla in the ABS committee room"—is that implementing an antibiotic stewardship program rarely occurs without resistance. Even when there's overwhelming clinical evidence that a certain medical protocol can lead to better outcomes, there will always be physicians who don't want to change.

Here, Edward Septimus, MD, FIDSA, FACP, FSHEA, clinical professor at Texas A&M College of Medicine, takes a look at the challenges ABS committees face when it comes to convincing their organizations' clinicians to rethink their approach to patient care and improving patient safety.

Dr. Septimus says that he sees physicians as falling into one of three “buckets": The first type, he explains, lacks knowledge about ABS best practices; the second is “insecure" and tends to over-treat; and the third is what he calls the “outlaw physician"— the doctor who doesn't want to be told by anyone how to practice.

The physicians who lack knowledge, Dr. Septimus says, tend to be relatively easy to work with. In his experience, the best way to win over these types is to provide them with the literature in a boiled-down format (like an executive summary), “so they don't have to read through a 30-page guideline." He also likes to assign mentors to the physicians “to help them get up to speed in terms of their knowledge until they feel more comfortable."

The physicians he describes as being “insecure," Dr. Septimus explains, “[do] not want to miss anything and sometimes can't see the trees from the forest." The best approach for them, he says, is to “sort of hold their hand and give them the fact that, 'You know, there can be unintended consequences of over-treatment.'" Explain that it's necessary to find a balance between one's clinical judgment and the clinical evidence, he recommends. “That one's a little bit tricky, but manageable."

Finally, for the “outlaw physicians," Dr. Septimus suggests showing them “how they compare with their peers, because physicians tend to be very competitive." When they see they're “behind" their clinical colleagues in ABS, they may decide to change their ways, he says. Another proven tactic involves inviting such physicians to step up and join the ABS committee themselves: “If you have someone who tends to be difficult but you can reason with them, sometimes if you get them on your committee, you can really bring them around."

The key thing to remember when it comes to convincing doctors they should follow the ABS committee's recommendations is “one size doesn't fit all," Dr. Septimus says. “It depends on the personality of the physician you're trying to influence." He doesn't believe in “embarrassing people," he notes, but he isn't afraid to “nudge" when it seems appropriate, and he believes in approaches like academic detailing. “That can be very powerful, where it's a one-on-one collegial conversation with your peers" and opportunities for improvement are debated and discussed.

In the end, Dr. Septimus argues, it's important to keep in mind that physicians can always override the laboratory's evidence-based order sets. Do your best—through the ABS committee—to show them the evidence, and when they do decide that an override is necessary, there's a good chance it will be for the right reasons.