Scientists have identified nearly 400 established medical practices that have been found to be ineffective by clinical studies published across three top medical journals.
Writing in the open-access journal eLife, the team hope their findings will encourage the de-adoption of these practices, also known as medical reversals, ultimately making patient care more efficient and cost effective.
Medical reversals are practices that have been found to be no better than prior or lesser standards of care, through randomised controlled trials (RCTs: studies that aim to reduce certain types of bias when testing new treatments).
But it can be difficult to identify these practices.
For example, Cochrane Reviews provide high-quality evidence on medical practices, but only one practice is covered in each review and many have not been reviewed in this way.
Additionally, the Choosing Wisely initiative in the US aims to maintain a list of low-value medical practices, but it relies on medical organisations to report them.
“We wanted to build on these and other efforts to provide a larger and more comprehensive list for clinicians and researchers to guide practice as they care for patients more effectively and economically,” says lead author Diana Herrera-Perez, Research Assistant at the Knight Cancer Institute at Oregon Health & Science University (OHSU), US.
To do this, Herrera-Perez and her team conducted a search of RCTs published over 15 years in three leading general medical journals: the Journal of the American Medical Association, the Lancet and the New England Journal of Medicine.
Their analysis revealed 396 medical reversals from 3,000 articles.
Of these, most were conducted on people in high-income countries (92%), likely because the majority of randomised trials are performed in this setting.
Meanwhile, 8% were done in low or middle-income countries, including China, India, Malaysia and Ethiopia.
Cardiovascular disease was the most commonly represented medical category among the reversals (20%), followed by public health/preventive medicine (12%) and critical care (11%).
In terms of the type of intervention, medication was the most common (33%), followed by a procedure (20%) and vitamins and/or supplements (13%).
“There are a number of lessons that we can take away from our set of results, including the importance of conducting RCTs for both novel and established practices,” explains senior author Vinay Prasad, Associate Professor at the OHSU Knight Cancer Institute.
“Once an ineffective practice is established, it may be difficult to convince practitioners to abandon its use.
By aiming to test novel treatments rigorously before they become widespread, we can reduce the number of reversals in practice and prevent unnecessary harm to patients.
“We hope our broad results may serve as a starting point for researchers, policy makers and payers who wish to have a list of practices that likely offer no net benefit to use in future work.”
Prasad adds that some limitations need to be taken into account with the results, including the fact that only three general medical journals were studied.
This means the findings may not be broadly generalisable to all journals or fields.
Additionally, other researchers may categorise results differently, depending on their expertise.
To help overcome this issue, the team invited physicians from a range of backgrounds to review and comment on the practices identified as reversals.
“Taken together, we hope our findings will help push medical professionals to evaluate their own practices critically and demand high-quality research before adopting a new practice in future, especially for those that are more expensive and/or aggressive than the current standard of care,” concludes co-lead author Alyson Haslam, Ph.D., also at the OHSU Knight Cancer Institute.
Causes of toxic practices
Toxic practices are the result of multiple converging factors however, three causes are most common:
First, no one is truly in charge of the practice.
Toxic practices are fueled by ignorance and fear because their leaders don’t know how to promote a mature, interdependent practice.
Individuals’ expectations for one another are not identified or validated. Ownership of a problem is usually pushed onto associates. Disruptive partners don’t respect the manager, do not accept coaching and usually are not confronted because of their status.
Second, because no one is clearly in charge, the ambiguity takes over. Individuals with strong control issues see the practice as their personal fiefdom and use their power to intimidate others into an authoritarian model.
These individuals may resist others’ input because of cultural or personality reasons. These people may use toughness or tyranny to escape their own fear of being controlled by someone else.
They are seen as despots who view all relationships as disclosing weaknesses.
Their fears cause them to feel no sense of compassion for their co-workers (who are perceived as dangerous). Their co-workers, in turn, reflect no compassion and isolate one other.
Third, the practice has no sense of unity or purpose.
The practice remains ineffective because the organizational teamwork that would produce a clear vision and realistic objectives is unknown.
Any attempts at practice efficiency are sabotaged by those who control by maintaining disorganization. They view clarification, measurable objectives and ownership of responsibilities as a threat.
CAUSES AND CONSEQUENCES OF TOXIC PRACTICES
No two toxic practices are alike. Some have a handful of issues to address; some have dozens.
All of them, however, are capable of driving good doctors into silent indifference or out the door.
Here are some of the most common causes and consequences of a dysfunctional office.
Dangers to your patients
A dysfunctional practice, like a dysfunctional family, breeds unhappiness. Disrespect and distrust fill the air.
But while a dysfunctional family sometimes can hide its troubles from the world, a dysfunctional medical practice cannot.
Your patients will sense that something is wrong. In a worst-case scenario, their care could suffer, despite your best efforts to preserve your clinical integrity. Even if their health remains fine, your patients will transfer out of your practice or become hypercritical.
Some of the patient-related problems are easy to spot. Difficult patient requests become too troublesome and are ignored. Even routine patient requests may be neglected. When patients do hear from the practice, communications are often curt.
Less obvious problems might pose the most danger to your patients. They can suffer when positive feedback is missing or performance appraisals are put off. Observations or hunches that can sometimes solve a mystery illness are not swapped in a dysfunctional practice. Even the benefits of attending CME programs are not shared in partner meetings.
A day in the strife
A dysfunctional office can wear out its members in endless ways, whether they’re new to the practice or have been around for years.
Disorder rules. Policies and roles are either not clarified or are changed at a whim. Expectations are unclear and unrealistic.
Discussion of the vision and development of an agreed upon strategic plan is avoided.
Employees are subjected to impulsive requests, have no sense of stability and feel compelled to conform to arbitrary control.
Their professional self-esteem is dependent on unpredictable forces.
They take out their stress on other colleagues, patients or family members.
Physicians avoid perfectly appropriate discussions about clinical care differences or dangers because they’re afraid of conflict or being shamed.
Mistakes may become more prevalent. Each physician maintains his or her own style to the detriment of office efficiency and quality patient care.
Staff ideas are rarely heard or elicited. Morale decreases. Staff quit, leaving the practice understaffed.
Loyalty is rewarded regardless of merit.
The staff emulates the attack mode of the leaders. Reduced cooperation and inefficiency permeate the practice.
What’s best for the practice becomes secondary to keeping your job.
Those with innovative ideas keep them to themselves because of the implied threat of personal attack. Trial and error isn’t allowed.
Faultfinding becomes the unintended obsession. Planning for the future, or efficiently managing the present, is not a priority. In such a practice, the physician who routinely is late, writes illegibly or controls the environment with his or her “good” or “bad” days is allowed to persist.
In a dysfunctional practice, peer appraisal and civil disagreement are not sanctioned. Greater anxiety is promoted. Denigration of topics such as stress management and well-being are put down and put off.
Dysfunctional practices do not reward collaboration and interdependence.
In cardiology or radiology practices, invasive and noninvasive specialists are pitted against each other. Prestige, income generation or case selection reinforce differences rather than blending into a whole group.
More information: Diana Herrera-Perez et al, A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals, eLife (2019). DOI: 10.7554/eLife.45183
Journal information: eLife , The Lancet , Journal of the American Medical Association , New England Journal of Medicine
Provided by eLife