The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes

In this interesting paper is a reference to one of the interviewees: "As one family physician said: I was being a little bit lackadaisical with the A1c goal as 7.0[%] or less. I wouldn't really like to admit it, but the insurance companies making a financial carrot is probably one impetus for really cracking down on my diabetics to get them 7.0[%] or less. 7.1[%] don't cut it...anymore. It has to be 7.0[%] or less." This one statement sums up many of the issues raised in this paper and raises critical questions for the practice of medicine. First is the issue of the A1c goal. It is assumed that A1c<7% is the appropriate goal for everyone and it is true that the HEDIS measure for glycemic control was A1c<7% for all patients with diabetes aged 18-74--no exceptions. In fact, this measure was strongly promoted by an aligned industry (BigPharma), professional societies, some government agencies, and others.(1,2) Following the early termination of the ACCORD Trial (and publication of that trial as well as VADT and ADVANCE) prompted revision of that measure. This constituted an excellent example of a performance measure proceeding without the necessary scientific evidence.(2) Now, "individualizing targets" which seems all the rage.(3,4) Despite voices calling for this intuitively obvious step, it took years before the groups who had pushed tight glycemic control so hard relented. It should, but doesn't, go without saying, that pursuit of tight glycemic control should have potential for benefit of that individual patient. The long time course for development of complications means that life expectancy enters into the decision-making calculus. Another assumption is that pursuit of tight glycemic control is without harm, most notably hypoglycemia. However, the frequency of hypoglycemia, even severe hypoglycemia (requiring third party assistance) seems to have been ignored.(5) Practicing clinicians knew otherwise, but studies documenting the high frequency and potential harms, e.g., falls in the elderly, have been slower in coming. Pay-for-performance is a form of cybernetic management: "quantified targets are set for performance at some point in the future, the time path towards the target is forecast, and then actual outcomes are measured and compared with forecasts, with the variance fed back to determine what adjustments are required to bring performance back to target." (6, p39). However, unlike that classic cybernetic system of a heater and a thermostat, in this P4P world, undertreatment is incentivized, but overtreatment is not dis-incentivized. Finally, what does this all say about professionalism? Nothing good, I am afraid. Fortunately, the data on the effectiveness of P4P are mixed at best.(7) That should give us some hope that clinicians are willing to use their judgment. However, there are too many instances of gaming to feel smug. In the end, we as clinicians should be partners with our patients to help them negotiate the challenges of chronic illness where tradeoffs of all sorts are required. Chronic illness is far too complex to be left in the clutches of the simplistic number crunchers.

David C. Aron, MD, MS The opinions expressed are my own and do not represent those of the VA or any other agency.

1. Aron D, Pogach L. Transparency standards for diabetes performance measures. JAMA 2009;301:210-212.

2. Pogach L, Aron DC. Sudden acceleration of diabetes quality measures. JAMA 2011 Feb 16;305(7):709-710.

3. Ismail-Beigi F, Moghissi ES, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing Glycemic Targets in Type 2 Diabetes Mellitus: Implications of Recent Clinical Trials. Annals Internal Medicine 2011;154(April 19):554-559.

4. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of Hyperglycemia in Type2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. Published online before print April 19, 2012.

5. Pogach L, Aron DC. The Other Side of Quality Improvement in Diabetes for Seniors: A Proposal for an Over-Treatment Glycemic Measure. Arch Int Med 2012; Less is More, online prior to print, Sept., 2012.

6. Stacey R D. Complexity and Organizational Reality: Uncertainty and the Need to Rethink Management after the Collapse of Investment Capitalism, 2nd edition, London UK; Routledge, 2010.

7. Van Herck P, De Smedt D, Annemans L, et al. Systematic review: Effects, design choices, and context of pay-for-performance in health care. BMC Health Services Research 2010;10:247

Competing interests:   None declared

The transcribed conversations reported by Hunt, Kreiner, & Brody (2012) give evidence that physicians in a variety of clinical settings are following very similar personal scripts. Scripts are habitual ways of thinking and interacting with patients around a medical problem (R. M. Hamm, 2003). Though perhaps no longer conscious, they are flexible, developed first during a physician's education but shaped during practice by new literature, interactions with peers, and reflection (Abernathy & Hamm, 1995). As the paper suggests, the high frequency of conversations with drug reps is probably one reason that most physicians' scripts for treatment of patients at risk of cardiovascular disease focus almost exclusively on the use of medication to attain blood pressure and blood glucose targets.

It is clear that these physicians' scripts leave out important considerations such as the patient as a person, adverse side effects, the cost of medications and the burden of managing multiple daily doses. It is also clear, from this and other studies (Fischer et al., 2009), that physicians don't accurately perceive how they are influenced: they say they view the marketers' information objectively, yet they prescribe the drugs they've been detailed on more often. This automated, unaware thinking is characteristic of physicians' use of scripts (R.M. Hamm, 2009). Script content depends on the strength of association between situations and the idea of doing an action, and that can be influenced by repeated exposure.

Scripts may also be influenced by unconscious norms of politeness. Receiving a gift activates the desire to reciprocate. One did not promise to prescribe, but only to consider prescribing; nonetheless, one prescribes. In social settings people refrain from criticizing others. Accordingly a physician may decline to argue every point that the pharm rep lays out as the clinic staff file past filling their plates. While the most authoritative physician in the room may be mentally adding that "grain of salt" to what the rep says, others in line see only that their lead physician seems to agree, so they assume the claims are accurate and add the possibility of using the drug to their own scripts.

If repeated messages so powerfully influence behavior, clinicians should make a point of verbalizing treatment strategies other than medication adjustment to reduce cardiovascular risk, and individual patient goals other than to those articulated in the generic guidelines. These statements should be repeated daily to oneself, to each other, and to patients. The physician's mind is important territory, for its contents determine how patients are cared for. It should be governed by physicians themselves, not colonized by whoever talks to them while buying their lunch. Perhaps physicians should buy each other lunch.

Robert M. Hamm, PhD

Department of Family and Preventive Medicine

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Abernathy, C. M., & Hamm, R. M. (1995). Surgical Intuition. Philadelphia, PA: Hanley and Belfus.

Fischer, M. A., Keough, M. E., Baril, J. L., Saccoccio, L., Mazor, K. M., Ladd, E., . . . Gurwitz, J. H. (2009). Prescribers and pharmaceutical representatives: why are we still meeting? J Gen Intern Med, 24(7), 795- 801. doi: 10.1007/s11606-009-0989-6

Hamm, R. M. (2003). Medical decision scripts: Combining cognitive scripts and judgment strategies to account fully for medical decision making. In D. Hardman & L. Macchi (Eds.), Thinking: Psychological Perspectives on Reasoning, Judgment and Decision Making (pp. 315-345). Chichester, West Sussex, GB: John Wiley & Sons, Ltd.

Hamm, R. M. (2009). Automatic thinking. In M. W. Kattan (Ed.), Encyclopedia of Medical Decision Making (Vol. 1, pp. 45-49). Thousand Oaks, CA: Sage Publications.

Hunt, L. M., Kreiner, M., & Brody, H. (2012). The changing face of chronic illness management in primary care: a qualitative study of underlying influences and unintended outcomes. Ann Fam Med, 10(5), 452- 460. doi: 10.1370/afm.1380

Competing interests:   None declared

Hunt, Kreiner, and Brody noted that "the clinical consultations we observed focused heavily on choosing and adjusting medications, to the near exclusion of other considerations, such as diet and lifestyle" (p. 455). But there is such good evidence that counseling patients to change diet and exercise behavior is effective in reducing cardiovascular risk (Fisher et al., 2011; Hankinson et al., 2010; Lin, O'Connor, Whitlock, & Beil, 2010; Ross et al., 2000). Extrapolating from the connection the paper makes between the frequent, friendly relations with pharm reps and the doctors' emphasis on using drugs to reduce the signs of cardiovascular risk, why aren't there diet industry reps and gym reps visiting doctors' offices? Buying lunch is not restricted to pharmaceutical and device manufacturers and the occasional academic detailer (Soumerai & Avorn, 1990). Given the focus of much of physicians' drug-rep sponsored activities (eating, recreation), young, slender, and fit representatives of the diet and exercise industries could naturally provide doctor and staff with healthy sample meals and gym visits, talking over carrots and curls about how patients' cardiovascular risk can be reduced through losing weight and lifting weights. Perhaps the problem is lack of monopoly; patients can go anywhere for help with lifestyle change, so a particular gym or diet program's investment in detailing would likely not pay off.

Ingrid E. Young and Robert M. Hamm

Fisher, E. B., Fitzgibbon, M. L., Glasgow, R. E., Haire-Joshu, D., Hayman, L. L., Kaplan, R. M., . . . Ockene, J. K. (2011). Behavior matters.. Am J Prev Med, 40(5), e15-30. Hankinson, A. L., Daviglus, M. L., Bouchard, C., Carnethon, M., Lewis, C. E., Schreiner, P. J., . . . Sidney, S. (2010). Maintaining a high physical activity level over 20 years and weight gain. JAMA, 304(23), 2603-2610. Lin, J. S., O'Connor, E., Whitlock, E. P., & Beil, T. L. (2010). Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med, 153(11), 736-750. Ross, R., Dagnone, D., Jones, P. J., Smith, H., Paddags, A., Hudson, R., & Janssen, I. (2000). Reduction in obesity and related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men. A randomized, controlled trial. Ann Intern Med, 133(2), 92-103. Soumerai, S. B., & Avorn, J. (1990). Principles of educational outreach ('academic detailing') to improve clinical decision making. JAMA, 263(4), 549-556.

Competing interests:   None declared

Hunt, Kreiner, & Brody's carefully researched and forthrightly written article may signal the state of affairs pertaining to a significant segment of the diabetes/metabolic syndrome patient population. The authors identify the potential harms of the recent expansion of and pressure to comply with early and intensive pharmacological algorithms for the management of type 2 diabetes.

There is a considerable and growing body of research supporting the assertion that iatrogenic prescribing habits, including inappropriate prescription, polypharmacy/over-treatment, and clinician inattentiveness to adverse drug response (which may engender further prescriptions rather than tapering or cessation of existing ones - the "cascading effect" identified by the authors), is common to many areas of medicine.

The authors identify several possible causes of harmful prescription practices, most tracing at root to the vast, all-encompassing pharmaceutical marketing apparatus. In my experience, most MDs ignore or mistrust studies about the effects of pharmaceutical marketing for two reasons. First, unbeknownst to them most pharmaceutical marketing in fact takes place where they cannot see it - at the level of the manipulation of clinical science and in efforts to influence professional, public, and regulatory judgment regarding the utility, efficacy, and pricing of proposed new drugs. As for the influence of drug reps, as reported in this study MDs tend to reject the insinuation that reps might have an effect on their decision-making. Every study conducted independently and by the pharmaceutical industry with which I am familiar, however, controverts this self-serving belief.

It may be unreasonable to expect to alter the marketing activities of big pharma. Their interests are too well-funded, and political and popular acceptance for their "free market" practices is too entrenched.

We can, however, aim to mitigate the iatrogenic effects of misinformed prescription practices by expanding and improving the data on drug safety. Research shows that 50% of people taking a medicine suffer an adverse event or side effect due to treatment. Independent research and statistics indicate that over 95% of adverse events remain unreported. When MDs do report it is often in cursory fashion, not addressing the human (quality of life) costs that patients who have been harmed must bear. In some fields, such as psychiatry, it is extremely difficult to distinguish the effects of the drugs from those of the sickness.

Our medical system is fixated upon efficacy of drug treatments to the detriment of bids to ascertain and classify side effects in sub- populations. Studies regarding the effects of dependency and withdrawal associated with long-term application of drugs are unpopular, even while the industry has shifted most of its energies to developing and promoting drugs designed for rest-of-lifetime use.

Neither the authors of this excellent study nor I are cynical as to the conscientious intentions of most clinicians. If physicians had at their disposal improved side effect data, made available to them through trusted, independent sources, the dangers of improper prescriptions would certainly be mitigated.

Kalman Applbaum Professor of Medical Anthropology University of Wisconsin, Milwaukee Founding Member, Data Based Medicine (https://www.rxisk.org/Default.aspx)

Competing interests:   None declared