I believe therefore....
From: Deborah Wage (wagedj@ctrvax.Vanderbilt.Edu)
Mon Jun 30 00:57:51 1997
For all that RCTs are worth (and that is alot), the ability to influence
a clinician's practice by showing 'the evidence' is futile when faced
with the bigger influence discussed in this letter. Sometimes, "To truly
understand one must unburden oneself from the yoke of rationality" Zan
Blue
Deborah
>
> The Lancet
>
> The Lancet is a copyright of The Lancet, Ltd, 1996, All Rights
> Reserved.
> ----------------------------------------------------------------------
> Volume 347(8993) January 6, 1996 pp 4-5
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> ----------------------------------------------------------------------
> ----------------------------------------------------------------------
> I believe therefore I practise
> [Commentary]
>
> Graham, Ian
>
> Loeb Medical Research Institute, Clinical Epidemiology Unit, Ottawa
> Civic Hospital, Ottawa, Ontario, Canada.
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>
> ----------------------------------------------------------------------
>
> ----------------------------------------------------------------------
> Outline
>
> * REFERENCES AND NOTES
>
> ----------------------------------------------------------------------
> Should one take account of practitioners' beliefs when attempting to
> ----------------------------------------------------------------------
> influence clinical practice? A recent report by Klein and colleagues
> ----------------------------------------------------------------------
> (1) answers this question with a resounding yes. These researchers
> analysed physicians' beliefs concerning episiotomy, and their
> behaviour and patient outcome, during a randomised controlled trial of
> episiotomy. (2) The purpose of this analysis was to explore some
> physicians' poor compliance with the trial protocol. During the trial,
> a third of the physicians did not change their use of episiotomy as
> required by the protocol and continued to use episiotomy almost 90
> percent of the time in both arms of the trial (one arm required
> restriction of episiotomy to fetal and maternal indications while the
> other required the more liberal or routine use of the operation).
>
> After the trial ended but before the results were released, Klein et
> al surveyed doctors who had participated and conducted a post-hoc
> analysis of the trial data. They divided them into quartiles based on
> the strength of the views that they held about episiotomy. The
> clinicians were categorised as having either very favourable,
> favourable, unfavourable, or very unfavourable beliefs about
> episiotomy. The researchers then compared the use of obstetric
> practices and subsequent patient outcomes of each of these groups of
> clinicians.
>
> Whilst characteristics of the women attended by each category of
> clinician were similar (eg, in terms of parity, age, height, weight
> gain, baby's birth weight), doctors with more favourable views of
> episiotomy were less likely to randomise women into the trial and more
> likely to justify the exclusion of women from the trial on the grounds
> of "fetal distress" or caesarean section than were their colleagues
> with very unfavourable views of episiotomy. Once a woman was
> randomised into the trial, these same doctors also had more difficulty
> limiting the use of episiotomy in the restricted arm of the trial.
> Compared with their colleagues with very unfavourable views of
> episiotomy, they were more likely to perform episiotomy when the
> protocol called for avoiding one, because they perceived the fetus to
> be distress or thought the perineum was unable to distend or was about
> to tear. Furthermore, women attended by these clinicians received more
> oxytocin augmentations of labour and had shorter labours than women
> attended by doctors with very unfavourable views of episiotomy. Klein
> et al concluded that physicians with more favourable views of
> episiotomy were more likely to consider apparently normal labour as
> abnormal and, in accord with this perspective, were also more likely
> to intervene in the birth process and use techniques to expedite
> labour.
>
> One could argue that the findings of Klein et al are of limited
> generalisability because the experimental design of randomised
> controlled trials runs counter to usual autonomous clinical
> decision-making and is therefore an anathema to the human spirit. (3)
> However, over the past century, one of the many factors that has been
> instrumental in influencing the use of episiotomy has been clinicians'
> beliefs. For example, during the late 1800s, physicians' beliefs
> effectively discouraged the acceptance of a "new" maternity
> practice-elective episiotomy. The liberal use of episiotomy advocated
> by numerous doctors during the latter decades of the 19th century was
> largely rejected because elective episiotomy went against the then
> prevailing obstetric belief in the "natural law" of the perineum,
> according to which Nature ensured the proper distension of the
> perineum during childbirth, making the use of perineal incision
> unnecessary in the vast majority of births.
>
> During the 20th century, routine use of episiotomy in the USA and
> liberal use of episiotomy in the UK eventually came about, but only
> after a radical shift in the obstetric belief systems of both
> countries. In the USA, the routine use of episiotomy, which became
> popular beginning in late 1930s, did so after obstetricians succeeded
> in recasting childbirth from a normal process that was thought to
> require very little intervention to a more pathological process that
> was believed to necessitate prophylactic intervention to diminish or
> prevent fetal and maternal damage. In the UK, the shift that removed
> some of the longstanding philosophical barriers to the more liberal
> use of episiotomy was the acceptance of "active management of labour"
> during the 1970s, the underlying principle being the superiority of
> obstetric intervention over physiological processes.
>
> Finally, the history of episiotomy reveals that clinicians do not
> always possess the same beliefs, and that competing belief systems can
> encourage and support change by offering philosophical justification
> for challenging existing practices. This has been the case with the
> questioning of the liberal use of episiotomy by midwives and general
> and family medicine practitioners on both sides of the Atlantic. These
> groups' belief in birth as an essentially physiological process not
> requiring routine surgical intervention has been central to their
> challenging of routine episiotomy.
>
> Proposed changes in practice are much more likely to succeed when they
> are compatible with existing beliefs. Conversely, belief systems at
> odds with a proposed change may discourage clinicians from seriously
> considering adopting the practice. When this occurs, it may be
> reasonable and necessary to modify the belief system to make it more
> congruent with the proposed change. Despite the growing interest in
> strategies to influence practitioner performance, (4-6) clinicians'
> beliefs are not explicitly or systematically receiving the attention
> they deserve. Policy makers and healthcare researchers, both those
> conducting randomised controlled trials and those interested in
> research transfer, should pay attention to this area. If they do not,
> we should not be surprised when the results of efforts to influence
> doctors' behaviour remain disappointing.
>
> Ian Graham
>
> Loeb Medical Research Institute, Clinical Epidemiology Unit, Ottawa
> Civic Hospital, Ottawa, Ontario, Canada
>
> References
>
> 1. Klein MC, Kaczorowski J, Robbins JM, et al. Physicians' beliefs and
> behaviour during a randomized controlled trial of episiotomy:
> consequences for women in their care. Can Med Assoc J 1995; 153:
> 769-79. [Medline Link] [Fulltext Link] [Back to Paragraph 1]
>
> 2. Klein MC, Gauthier RJ, Jorgenson SH, et al. Does episiotomy prevent
> perineal trauma and pelvic floor relaxation? Online J Curr Clin Trials
> 1992; July 1 (doc 10). [Back to Paragraph 1]
>
> 3. Schulz KF. Editorial: Unbiased research and the human spirit: the
> challenges of randomized controlled trials. Can Med Assoc J 1995; 153:
> 783-86. [Medline Link] [Fulltext Link] [Back to Paragraph 4]
>
> 4. Oxman A, Thomson MA, Davis D, Haynes RB. No magic bullets: a
> systematic review of 102 trials of interventions to improve
> professional practice. Can Med Assoc J 1995; 153: 1423-31. [Medline
> Link] [Fulltext Link] [Back to Paragraph 7]
>
> 5. Davis D, Thomson MA, Oxman A, Haynes RB. Changing physician
> performance: a systematic review of the effect of continuing medical
> education strategies. JAMA 1995; 274: 700-05. [Medline Link] [Back to
> Paragraph 7]
>
> 6. Grimshaw J, Freemantle N, Wallace S, et al. Developing and
> implementing clinical practice guidelines. Qual Health Care 1995; 4:
> 55-64. [Back to Paragraph 7]
>
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