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How to "nudge" doctors into prescribing fewer antibiotics

Photo by Frank Bienewald/LightRocket via Getty Images
Brian Resnick is Vox’s science and health editor, and is the co-creator of Unexplainable, Vox's podcast about unanswered questions in science. Previously, Brian was a reporter at Vox and at National Journal.

As we recently learned from a paper published in JAMA, an eyebrow-raising 30 percent of antibiotic prescriptions in the United States are unnecessary. As Vox's Julia Belluz reports, the majority of these prescriptions are for viral infections. Which is ridiculous: Antibiotics don't work against viruses. Period.

When doctors prescribe antibiotics needlessly for things like colds, more bacteria become resistant to them. It's simple evolution. In any given population of bacteria, there may be a few with the genes to survive an antibiotic chemical assault. Those bugs then multiply.

In the past, medicine has fought back by developing new antibiotics. But the rate of new discoveries has slowed to a near halt. Now there are "superbugs" impervious to most (in some cases, all) antibiotics known to science, and they're very deadly. Think MRSA, "super gonorrhea," and CRE (a.k.a. "the nightmare bacteria").

The Centers for Disease Control and Prevention estimates that 23,000 people died from resistant infections in 2013. It's been estimated that by 2050, antimicrobial resistant diseases will kill more people than cancer.

So this is a serious problem. And it's why researchers say we have an urgent question to answer: How do we help doctors prescribe fewer unnecessary antibiotics?


American doctors have made a remarkably big contribution to antibiotic resistance

Doctors should — and do — know better than to prescribe antibiotics when they don't have to. But when it comes to interacting with patients, physician often cave. "The patient that is in front a doctor at any given time may not be the one affected by [antibiotic resistance]," says Daniella Meeker, a professor of preventive medicine at the University of Southern California. This clouds doctors' judgment. Like the slow-moving disaster of climate change, it's hard to see consequences of antimicrobial resistance in the day to day.

Meeker says the solution is not to teach physicians to make better decisions. And there's not great evidence that financial incentives work either. What works is to pressure doctors to make better decisions. And so far, these methods have been shown to be surprisingly effective at reducing unnecessary prescriptions.

How social pressure makes doctors better doctors

Alex Proimos / Flickr

In recent years, psychologists have embraced a concept called "nudging." It’s all about how to help people make better decisions.

Social pressure is a powerful psychological tool for nudging. We want to be seen well in the eyes of our peers. They hold us accountable for our actions.

In February, Meeker and colleagues published results in JAMA that found just a nudge of social pressure could reduce the rate of bad prescriptions from a baseline of 24.1 percent to 3.7 percent. (A control group also decreased to 13 percent, which suggests enrolling physicians in a study where they know they're being monitored is enough to change behavior.)

"Physicians are professionals, and they have to maintain a professional self-image for their livelihood," says Jason Doctor, a USC psychologist (so yes, Dr. Doctor) and senior author on the paper. "A lot of our interventions that have been successful leverage that … physicians really do respond to social incentives — and they’re powerful."

Here's what they did.

A total of 248 clinicians were assigned to one — or a number of — the following interventions.

1) "Accountable justification": In this condition, doctors had to justify each antibiotic prescription with a small block of text in a patient's chart. Other physicians in the practice could read these notes if the patient returned.

2) "Peer comparison": Doctors received monthly emails comparing their faulty prescription rates with those of their peers. (Their prescriptions were monitored by a computer and then checked by one of the investigators). Doctors who were giving out too many unnecessary antibiotic prescriptions were told, "You're not a top performer." Ouch.

3) "Alternative treatments": The last intervention didn't have a social component. Simply, when doctors entered patients' information into a computer, the computer would second-guess them. If the physicians had given antibiotics when they weren't indicated, they'd see a prompt that said, "Antibiotics are not generally indicated for this diagnosis." The prompt would then suggest alternatives.

Doctors want to save face

The study ran for a total of 14,753 patient visits and found that the first two interventions made the biggest difference compared with the control group.

"Accountable justification" decreased bad prescriptions rates to 5.2 percent (from 24.1 percent baseline). "Peer comparison" was a bit stronger, reducing rates to 3.7 percent.


The third intervention — "alternative treatments" — did decrease prescribing, but it didn't yield statistically significant results compared to control. And remember, the control condition itself saw a remarkable decrease. The study also found no evidence that the physicians were missing correct prescriptions for antibiotics under the right conditions.

There are a few limitations to the study. One is the relatively small number of physicians enrolled. The second is the fact that physicians who willingly enroll in this type of trial are more willing to change their behavior.

But the results jibe with previous work on the topic. One previous paper found that just putting a poster on a physician's wall — a poster that contained a letter where the physician stated his or her commitment to fight unnecessary prescriptions — reduced bad prescriptions by 19.7 percent.

Doctors aren't perfect. We need to bolster them to combat antibiotic resistance.

The big idea behind all these results is this: When you nudge doctors to consider their self-image, they make better decisions. Sometimes these techniques are characterized as "shaming." But Jason Doctor says that's not the right way to think about it. "It’s not shaming because we’re not publicly exposing them," he says. "And when we say that we might, we give them the opportunity to write about why they were doing something."

All said, these interventions are all relatively easy to implement without obvious downsides. In the study, Doctor and Meeker also looked to see if the interventions hindered correct prescriptions. They didn't. There was a small 1.4 percent uptick in return visits for patients visiting doctors in the "accountable justification" condition. But this is hard to interpret, as the other intervention groups — including the offices that had all three interventions going on at the same time — didn't see an uptick.

(Though they don't have data for opioid prescriptions, Doctor and Meeker suspect similar techniques may help physicians make better prescribing decisions in that realm as well.)

One of the key insights of Doctor and Meeker's work is that in 2014 they and colleagues found that the rate of bad antibiotic prescriptions increases throughout the day. Doctors prescribe more unneeded antibiotics in the afternoon. The reason is simple: Physicians make worse decisions later in the day because they're human — tired and stressed out like the rest of us. All people are susceptible to exhaustion and prioritizing easy, short-term decision-making over what's best for the future.

Instead of blaming them for the looming antibiotic resistance crisis, we should be bolstering them. And that means in the split-second decision of whether to prescribe a patient antibiotics when they aren't needed, we should design systems that nudge doctors in the right direction.

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