We’ve been closely following the controversial ORBITA study, a double-blind, placebo-controlled trial that challenged long-held beliefs about the benefits of stents for patients with stable angina. Clinicians and researchers such as Vikas Saini, David Brown, and Rita Redberg see ORBITA as an extremely significant trial that will shift practice in cardiology away from unnecessary interventions.
But will this new evidence be enough to actually change clinical practice? Health services expert and Right Care Alliance member Douglas McKell explains some of the barriers to clinical change. McKell is a faculty member at the Doctoral Nursing Program at the Elms College School of Nursing, specializing in quality improvement, organizational management, and interpersonal leadership.
We all know the law of inertia, that an object in motion or at rest will stay that way unless acted on by a force. The same principle applies to our routines and normative practices, says McKell.
“We all have an inherent conservative bias, a tendency to not want to change what we’re currently doing,” says McKell. So the evidence needs to be extremely strong to shake us out of our habits. After all, the evidence physicians read in journals is competing against a wealth of evidence, both clinical and anecdotal, from years of practice that may lead them to a different conclusion.
And that’s all assuming that ORBITA can be replicated, in a sample with clinical diversity, that can be generalized to broader populations, and that we aren’t missing other benefits to stents that aren’t measurable. But even strong evidence may not be enough because…
Loss aversion is a key principle in behavioral economics. Put simply, we feel the loss of something greater than we feel the gain from something.
This matters in clinical practice because if a patient thinks there is something that will help their condition and then they don’t receive the intervention, they will perceive it as a loss. This potential loss may be scarier than the potential benefits of avoiding surgery.
Physicians also feel the loss of positive patient outcomes very acutely, says McKell. For example, some cardiologists have responded to ORBITA with letters showing how much better their patients felt after getting a stent (see left), as proof that it’s worth still doing stents.
It seems irrational to use anecodtal evidence in the face of a randomized controlled trial, but it makes total sense to McKell why doctors would do this.
“Getting letters from patients who feel better is an emotional lift doctors don’t want to lose,” says McKell. “They did something and it was the right thing, and there was improvement. You feel the loss of that greater than the win.”
In short, doctors love making their patients feel better, and they don’t want to lose the feeling of having made their patients happy.
Along that same line, it’s hard to tell most doctors and patients that doing nothing is better than doing something.
“We’ve created a mythos that going to the doctor results in some sort of action,” says McKell, “Providers are no more immune to that than patients.”
And for clinical change to be successful, both physicians and patients have to be on board. Even if the evidence shows a particular intervention isn’t effective, and the doctor pushes for not doing the procedure, the patient still has to be okay with doing nothing in the face of pain and anxiety. It’s hard for a doctor to use intellectual arguments against a patient’s emotional reality.
“Common sense would tell us that exposing patients to risk for an unnecessary procedure is incorrect, illogical and potentially harmful,” says McKell, “However, the emotional pull to ‘do something’ is indeed very powerful, especially during short provider-patient encounters.”
But it’s not all bad news! There are plenty of doctors and patients working hard to fight the structural and behavioral forces toward overuse.
“It appears that people are becoming more cautious about procedures, especially when the complications are known,” says McKell, “We’re starting to ask, is this system sustainable?”
One method for reframing the stent conversation is by focusing on preventable complications as benefits, rather than the “uselessness” of stents. Some cardiologists like John Mandrola and Mohamed Elshazly have responded to critics by saying that ORBITA should be seen as good news, because fewer patients will be exposed to potential risks of stents.
The barriers to change on this issue are formidable, but with hopefully with more evidence, education, and honest discussions between providers and patients, we can achieve change.