J.R. Schmitt tipped me off to a fascinating article published in 1997 (!) about a “de-marketing strategy” for the use of general anesthesia in dentistry in the UK:
De-marketing: Putting Kotler and Levy’s Ideas into Practice, by Steven Lawther, Gerard B. Hastings, and R. Lowry
(Be patient – you have to zoom and scroll to read the full paper, but it’s worth it.)
It seems that many dentists were putting patients under general anesthesia when it wasn’t strictly necessary and despite the known risks. Children were particularly likely to be put under. Older dentists were more likely than younger dentists to recommend general anesthesia. And there were regional hot spots: if a certain practice had invested in the expensive equipment required, they were more likely to use it (of course).
The authors conclude that the best way to change the culture is to create a collegial environment and gently change dentists’ minds. The authors cautioned that those at the “sharp end” of clinical practice, who engage in “wet-fingered dentistry,” would bristle at the idea of being told what to do by central authorities. So: no sudden billing changes or other mandates. The authors also did not see a role for patient education. I’d love to hear what others’ think of the article — and if anyone knows if this practice of general anesthesia in dentistry has indeed ebbed in the UK.
I’m reminded of a January 2012 Boston Globe article reporting on a study showing How Facts Backfire:
I believe the Globe article is based on Nyhan & Reifler’s 2010 journal article, When Corrections Fail: The Persistence of Political Misperceptions. Political Behavior 32(2):303-330 (a 2006 preprint of which can be found here). FWIW, the article also references earlier related work by James Kuklinksi, et al., which I believe is based on the 2000 journal article, Misinformation and the Currency of Citizenship. Journal of Politics, 62 (May 2000): 791-816.
While much of this research has focused on political perspectives and biases, Jonah Lehrer compiled some additional related research showing that the cognitive cost of expertise – being resistant to facts that don’t fit our theories or practices – is pervasive in other fields as well.
I love the closing lines of Lehrer’s article:
“So if you’re an expert, be proud: You’ve learned to perceive the world in a useful way. Your training has changed the structure of your brain. But don’t forget to think about your blind spots, about all those new patterns that you must struggle to see.”
The authors of the de-marketing paper were pointing out some dentists’ blind spots – their refusal to consider the safety data related to general anesthesia.
All these years later – 15! – we can see another blind spot. Patients and their families had little hope of communicating or organizing, even if they became educated about the risks of general anesthesia in 1997. But now they can.
Thanks for the resources and for sparking new ideas!
Sorry for the delay in responding on this. I’ll see if I can rope in some UK friends, and perhaps some dentistry friends.
I took the liberty of re-tagging this article to add “Practice Variation,” because that’s exactly what you’re describing. And in particular, in my personal experience talking to docs of varying ages, the resentment about “don’t tell me how to practice my craft” is far more prevalent among docs trained in a long-gone-by era.
We talk here about the autonomous patient (chapter 7 of Doc Tom’s white paper); more than once I’ve been told by a doctor that he (always a he, in my case) wants his autonomy.
I can empathize with that. Otoh, my view is that patients need to be aware that a confident physician may be confident in one point of view, whose priorities may vary from the patient’s own.
I’ll see what my shared decision making / practice variation guru friends think.