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CHANGING PHYSICIAN BEHAVIOR:
In Search of the Little Blue Button*
John R. Kimberly
Summary
This paper addresses the topic of non-economic inf luences on
physician behavior as part of the Institute of Medicine's study on
strategies for reform of physician payment. The paper is not an
exhaustive review of the literature; rather it is intended to synthesize
what is known in a manner that highlights potential policy options. The
underlying question of interest is how might what is known about
non-economic inf luences on physician behavior inf luence policies designed
to change that behavior. Where is the little blue button?
Five categories of non-economic influences are particularly
noteworthy: education, feedback, managerial and organizational
constraints, peer pressure, and patient demands. The potential value of
education is based on the assumption that there is a connection between
cognitive change and behavior change. If physi clans know, for example,
that the benefits of a particular procedure do not come close to the
costs of that procedure, the hope is that they will be disinclined to use
it. In the absence of such knowledge, the argument goes, no behavior
change should be expected. Is having the knowledge, however, suff icient
for producing the desired change?
Feedback is a potentially powerful shaper of behavior. The notion is
straightforward. In the normal course of practice, physicians get
feedback in a variety of informal, generally unsystematic ways. Were
formal, systematic feedback on selected aspects of their practice
regularly available to physicians, they would be in a position to judge
whether they wanted to change any of these aspects. For the motivational
potential of feedback to be realized, the physician must be able to
compare not only his present practice patterns with his own past patterns
but also, and perhaps more importantly, he must be able to compare his
pattern with the patterns of other physicians in comparable sett ings.
*I would like to thank many of my colleagues at the Leonard Davis
Institute for Health Economics at the University of Pennsylvania for
contributing to the pool of ideas f ram which this paper emerged. They
are blameless for the product but entirely culpable for the stimulation
and provocation.
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As professionals, physicians are susceptible to inf luence by other
professionals whom they particularly respect. Although cliff icult to
quantify its effects, peer influence appears to shape important
dimensions of clinical practice such as test ordering, preferences for
drug perscription, and technology utilization. Peer influence also
shapes behavior in more subtle ways, and undoubtedly influences, at least
at the margins, important non-work values and attitudes as well.
The contexts in which physicians practice medicine are changing
rapidly. One of the most striking changes is the increasingly
organizational character of those settings. As a result, physicians are
more subject to managerial and organizational constraints than at any
time in the past. Their work will be more carefully scrutinized, and
organizational priorities will have to be integrated with professional
priorities. The traditional autonomy that physicians have enjoyed will
inevitably diminish somewhat as their work is subject to managers' needs
for coordination and control. To the extent that physicians become
employees of organizations (which they themse Ives may or may not own I,
they become subject to new constraints and controls which will influence
their behavior, economic and non-economic.
Education, f eedback and peer inf luence do not appear to be
signif icant, enduring influences or behavior in and of themselves.
Rather, their effects are most powerful in concert. Initiatives designed
to change physician behavior, therefore, ought not to focus exclusively
on one of them. To the extent that any given intervention can
incorporate all three sensibly, it stands a better change of having a
more profound, more enduring impact. For this reason, the increasingly
organized character of medical practice is significant. Organizational
settings where physicians are using their professional skills in close
proximity to other physicians and where other links may be established
among them provide unusually good opportunities to incorporate all three
effectively.
Patient demands are perhaps less amenable to policy initiatives, but
are nonetheless an influence on physician behavior which deserves
mention. Assuming that the vast majority of physicians want to practice
good medicine, and assuming that an important part of their sense of
professional competence comes from the affective quality of their
relations with patients, they may be more open to influence from their
patients than we might believe. As patients become more sophisticated'
ask more questions, and begin to assume greater responsibility for
personal health and medical decisions, we can expect the nature of the
inf luence process in the patient/physician encounter to change.
These five categories of non-economic influences must be considered
in the context of the changing environment in which the physician
practices medicine. The changing demographics of the population, the
increased emphasis on efficiency in the settings in which they practice,
increased competition among physicians for patients, and the spread of
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corporate medicine all signal rather dramatic changes in the matrix of
incentives to become a physician and in the structure of rewards for
being a physician. Policy initiatives intended to influence physician
behavior must be built on an awareness of differences among physicians
currently in the profession and on their effects on the process of
recruitment of new blood to the profession.
Introduction
This paper is designed to stimulate reflection on some of the key
non-economic influences on physician behavior. It is not a comprehensive
review of research on that and related topics. Such a review might be
useful, but would require excursions into the disciplines of psychology,
social psychology, sociology, and anthropology as well as the medical
literature. The more limited objectives of this paper required a more
selective review strategy.
Two questions were posed initially by the topic, and the answers
helped shape the approach taken. First, what are ~non-economic.
influences? The answer to this question proved elusive. An effort to
develop a definitive answer would have perhaps been theoretically
interesting, but as a practical matter would have led us far afield.
Because the boundaries between economic and non-economic influences are
hazy at best, we decided to focus on factors whose primary influence
appeared to be non-economic. Even this distinction is imperfect, but it
permitted us to move off dead center. Theoretical purists may yearn for
more rigor, and undoubtedly the issue deserves more attention than we
were able to give it.
A second question posed at the outset was what kinds of physician
behaviors should receive attention? It is tempting to distinguish
between clinical and non-clinical behavior, and, indeed, much of what has
been written uses this distinction either explicitly or implicitly.
Studies of physician use of new technology, test ordering, or drug
prescribing, for example, focus on clinical behavior. The distinction is
useful as a way of talking about what has been written (the vast majority
of which looks at clinical as opposed to non-clinical behavior) but may
be less useful in thinking about policy options. We will return to this
issue later in the paper, but for now let us raise the possibility that
the distinction unnecessarily constrains the way we think about how
behavior might be influenced.
With these two questions at least confronted--if not resolved--the
literature was reviewed selectively, principal themes were identified,
and implications were explored. The three main sections of the paper
which follow contain the essence of this work. Section I I, Primary
Influences, briefly reviews some of the basic research and then
synthesizes the most policy-relevant work into the five headings noted
above e Fortunately or unfortunately--it is a matter of perspective--the
world does not hold still. In Section III some of the more significant
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changes in the environment of the medical profession and its practice are
noted. The purpose is to highlight the fact that new policy initiatives
need to be based on informal predictions about the direction and impact
of these changes rather than on the existing order. Moving targets are
more difficult to hit, to be sure, than stationary ones--particularly
when there is considerable uncertainty about their direction and
velocity--but treating a moving target as though it were stationary is to
guarantee a miss.
The final section of the paper suggests an alternative way of
thinking about influences on physician behavior and proposes a set of
research questions that need to be asked if one goal is to move beyond
present levels of understanding.
Primary Influences
Career Choice. A great deal of ef fort has been invested in
understanding the various kinds of career choices that physicians make.
The choices themselves are varied: choice of medicine as a profession;
choice of medical school; choice of internship and residency; choice of
specialty and sub-specialty; choice of academic medicine versus private
practice; choice of location of practice; choice of setting for practice;
and choice of kinds of patients to serve. Studies that have been done
are primarily correlational or associational, that is, the outcomes of
these choices for individual physicians are correlated across large
numbers of physicians in an ef fort to detect patterns. Exceptions are
studies of medical education and its influence on how future physicians
are socialized into the profession.] These studies tend to be done in
the field and examine the decision process up close. The primary
findings, of course, are that medical school is a powerful socializing
agent, that future physicians are often strongly influenced by faculty
role models, and that one consequence is often a devaluing of general
practice or primary care and an over-emphasis on specialty practice.
Non-clinical professional behavior. In this category are studies
which in practice explore a relatively limited range of behaviors but
which to be more useful should broaden that range. Examples of this kind
of behavior are variability in physician travel to professional meetings
and variabilitly in reading of scientific literature related to
professional practice. Such issues are rarely the primary focus of
study. More often these variables are included as part of a study of
something else, and the results are generally correlational and thus of
limited value in other than a descriptive sense. Studies with these
variables included are relatively few in number. Fewer still are studies
of non-clinical professional behaviors of considerable current interest
to policy makers, such as political activity in professional associations
or involvement In administrative or managerial roles. Even descriptive
information here would be helpful.
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The basic conclusion is that, for whatever reasons, non-clinical
professional behavior has not attracted much research attention. Whether
more attention would be productive is a question well worth addressing.
Clinical decision-making. A great deal of research has been done in
this arena, primarily because of the potential attributed to changing
certain aspects of clinical behavior for controlling the costs of medical
care.4 If physicians would order fewer laboratory tests, prescribe
fewer drugs, and be less inclined to use expensive technology of
questionable efficacy, the aggregate impact on costs would be
significant, the argument goes.
There is considerable evidence that the problem of overutilization is
real, particularly with respect to test ordering and use of
technology. The explanations vary. Younger physicians tend to order
more tests than older ones. Internists in academic health centers tend
to order more than in other settings. Is the explanation age-centered,
setting-centered, or both? With respect to technology, the problem
appears to be the demand of physicians for the latest developments,
independent of demonstrated clinical efficacy.6 Once the technology is
available in an institution, there are pressures to use it. What
explains the rapid diffusion of essentially unproven technologies? The
dominant explanation appears to be, in the hospital setting, physician
pressure. Yet one has to wonder whether this explanation ignores some of
the complexity of the physician/institution relationship. At the very
least, one has to wonder how all this may change as we move from
cost-based to prospective reimbursement.
Given the widespread belief that change in clinical behavior is
something that is worthwhile pursuing, a number of studies have reported
the results of experiments designed to produce such change. Some
experiments have involved educating physicians about the costs of the
tests they order.' The idea is that, absent such information, there is
no reason to expect physicians to change. Knowing costs, however, might
affect their decisions. Other experiments have used feedback to
physicians about certain aspects of their clinical behavior compared with
others in their institution and others with similar patients in similar
settings.8 The idea here is that if physicians observe differences
they will be motivated to change. The assumption, of course, is that
physicians who see themselves, for example, as ordering comparatively
more tests for their patient with similar problems will be encouraged to
order f ewe r tests . Less attent ion has been f ocused on the case of the
physician who uses relet ively fewer tests. Will he be encouraged to
order more?
The results of these studies provide hope if not certainty.
Educational efforts have proven successful, if only for a short time.
Feedback has proven to be a motivator of change, although not equally
powerful under all circumstances and for all physicians.9 Variation in
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utilization of resources is real, dif ferences in the clinical behavior of
physicians accounts for a large part of this variation, and this behavior
is susceptible to change. Precisely how and under what conditions
remains somewhat cloudy.
Other studies cite the importance of opinion leadership in
influencing the clinical behavior of physicians. Perhaps the best-known
of these studies focused on patterns of diffusion of a new drug among
physicians and discovered that a very few well-respected physicians had
an enormous influence on their colleagues.l° These physicians were, in
effect, gatekeepers. When they began prescribing the drug, the green
light quickly flashed to their colleagues. The implications of this
study certainly have not been lost on the pharmaceutical industry.
Physicians in most respects are like anyone else. They have role
models. They mirror the values of and try to emulate those whom they
respect. They have self-doubts and anxieties. They are, in other words,
susceptible to a whole range of influences on their behavior, many of
which are economic but many of which are not. In a very real sense, the
nature of a physician's work and more important, the attributions we make
toward it make it difficult for us to see the uncertain, trial-and-error,
non-scientific context of the world he inhabitse We are thus less able
to appreciate the power of the mot ivational levers that are available and
are perhaps less able to see the levers themselves. As many observers
have noted, the contexts in which most physicians work most of the time
are loaded with incentives for greater rather than reduced use of
resources.ll The challenge is to understand the incentives, the
contexts, and human behavior well enough to know which levers are there
and which to pull.
The social context and normative understructure of physician
behavior. Some researchers have tried to understand physician behavior
by observing it in situ. The use of anthropologically-inspired
ethnographic methods has its drawbacks, as the recent controversy over
Margaret Mead's early writings suggests.12 Nevertheless, there are
some themes that emerge from the research that has been done that deserve
careful attention. Most significant is the power of the informal
normative structure that evolves wherever physicians work together. The
informal norms define the ranges of acceptable and unacceptable behavior
on a whole series of dimensions. They define what clinical mistakes are
and how they will be handled. They define a code of ethics for that
setting.13 And undoubtedly they define the parameters within which
economic incentives will operate. What is particularly noteworthy is
that these norms operate outside of formal rules and regulations. They
are the equivalent of local interpretations. They may operate in concert
with the formal rules or they may act as a buffer between those rules and
what phys icians actually do. And a [though there are undoubtedly certain
norms that operate at the level of communities, the most powerf ul
influences on physician behavior on a day-to-day basis are those that
operate in their immediate environment. As the sites where physicians
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work assume an increasingly organizational character, this will mean that
influences will be felt primarily at the organizational and departmental
levels.
Implications. We have skimmed over the surface of what is really a
substantial body of literature on physician behavior. Much of this
literature is descriptive; relatively little of it is straightforward in
its implications for policy intended to change that behavior.
Nevertheless' we know enough at this point both about physician behavior
and human behavior in general to be able to extract f ram what has been
written a limited set of variables on which to place our bets. Assuming
that the goal is to change physician behavior, we should bet on a
combination of education, feedback, peer pressure, organizational and
managerial constraints, and patient demands.
It is of ten suggested that because of the early and powerful
influence of medical education on subsequent career choices, the most
direct and effective way to change physician behavior is to change the
structure, context and process of medical education. I do not disagree
that such change would be helpful. However, I believe that the lasting
influence of the experience may be over-estimated and the difficulty of
producing major change in medical education may be under-estimated by
those advocating this strategy. As a practical matter, therefore, I
choose to emphasize the f ive variables noted above. Efforts to rethink
the structure, content and process of medical education should continue.
In the near term, there are other initiatives that may be taken as well.
By education, I mean increasing the knowledge that practicing
physicians have about selected aspects of their practice. It has been
demonstrated that overuse of resources can be reduced by a program
deliberately designed to educate users about such things as cost.14
Lack of awareness of cost may contribute to overuse. Education may help
solve the problem. The question which has arisen is how long we can
expect education effects to persist. Given that the effects do not
appear to be permanent, the conclusion is that education may be helpful,
it certainly ought to be incorporated more widely, and that it is not
sufficient to achieve the des i red resu 1 t .
By feedback, I mean providing physicians with information about
selected aspects of their own past and current patterns of practice and
the practice of others in similar settings with similar patients so that
they can see how their patterns have changed and where they stand
relative to their peers.15 The presumption is that once they are aware
of these two dimensions they may be motivated to change. The absence of
feedback affords them little opportunity to raise the question about
whether change should be contemplated or to make the judgment about where
change should take place and why. As with education, one can question
the permanence of the effects of feedback. More to the point, however
one can also ask how feedback should be designed in order to enhance its
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effectiveness. Here the worlds of medicine and management intersect in
what might prove to be an interest ing and product ive way.
The influence of peers is powerful. The theme runs throughout the
literature on physician behavior in more and less explicit ways. And it
certainly pervades more general theories of human behavior. To
oversimplify the message only somewhat, physicians, like other people,
are ~nf luenced in a variety of ways by their peers. Two aspects of peer
inf luence are particularly relevant here. First is the importance of
what have been called Opinion leaders.. These are the surprisingly
small number of individuals to whom others look for signals about what is
legitimate and valued. Identification of opinion leaders and changing
their behavior is a potentially powerful and efficient way to engender
broader-based behavior change. 16 Second is the development of what we
referred to earlier as the normat ive understructure of physician
behavior. These norms are held, transmitted, and enforced by peers.
Change in these norms is unlikely to occur without widespread peer
approval and support. The implication here, though perhaps obvious, or
perhaps because it is obvious, is often overlooked by those who would
create change. The result repeatedly is change in veneer without change
in substance.
Managerial and organizational constraints may be the focal point for
education, feedback, and peer influence. None of those three in
isolation is likely to produce the enduring changes in physician behavior
that many are searching for. To the extent that current trends for
physicians to exercise their profession in increasingly organized
settings continue, opportunities to influence their behavior will
flower. Possibilities for linking educational efforts with regular,
systematic feedback and capitalizing on the power of peer influence are
dramatically enhanced when physicians are working in close proximity and
are sub ject to a common admi nistrat ive system, no matter how loosely or
tightly def ined that system may be. Enough is known about designing
education and performance feedback systems and about capitalizing on the
power of peer pressure to permit policy initiatives to take advantage of
the increasingly organized character of the practice of medicine.
Patient demands are less amenable to policy initiatives (although
second opinion experiments may have encouraged patients to be less
reticent to question their own physician) than the foregoing, but their
inf luence on physician behavior deserves recognition. In fact, as one
ref lects on the social context of medical practice and how physicians
develop feelings of personal competence and self-worth, the influence of
patients on physi clan behavior may be greater than we think. Two trends
are noteworthy. First is the increasing sophistication of the patient.
Patients appear to be more likely to ask questions about diagnostic and
therapeutic regimens now than previously. They appear, in other words,
to be less likely to be passive ~ n their relationships with physicians
than has been the case historically. To the extent that this trend
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continues, physicians will be increasingly constrained to think through
and justify their clinical decisions to their patients. One might expect
that this phenomenon alone would inf luence physician behavior. The real
question, of course, has to do with the direction of this inf luence.
Assuming that it is in the physician ' s interest to be respons ive to
patient demands ~ in part as a consequence of increasing competition among
physicians for patients and the need to protect markets, the second trend
alluded to above), one can imagine a price-sensitive, procedure-skeptical
patient inf luencing the physician and, in the aggregate, the system, in
an ultimately cost-containing way. On the other hand, one can imagine
the physician interested in being responsive to patient demands giving a
price-sensitive, procedure-oriented patient what he or she wants (within
limits) thereby contributing to the cost spiral. Both scenarios are
over-simple, of course, but the point is that the patient may have
considerable leverage on physician behavior. If this possibility is
acknowledged, then one policy orientation might be in the direction of
producing price-sensitive, procedure-skeptical patients. What the most
efficient vehicles for doing this are is open to discussion, and many
different proposals eve been advanced. The basic point is that the
inf luence of the patient on physician behavior is substantial and its
potential ought to be incorporated into thinking about policy options.
To summarize, the most signif icant non-economic influences on
physician behavior are education, feedback, peer pressure, managerial and
organizational constraints and patient demands. Working these one at a
time, or not appreciating their joint effects will diminish substantially
their potential to produce significant, enduring change in the way
physicians do their business. Furthermore, exploration of their effects
has been limited primarily to clinical behavior. Less is known about
influences on career choice, non-clinical professional behavior, and
behavior apart f rom the profession which may affect professional
behavior. Each of these behavior domains could be more throughly
researched with great profit.
Clinical uncertainty. In a view that leads in a parallel direction
for policy, one relatively common explanation for overutilization of
resources is the way in which physicians seek and use information in
clinical practice. Faced with uncertainty and not wanting to co~Tunit
er rors of omission the argument goes, the physician tends to gather as
much information as possible in the course of dealing with the patient,
regardless of cost. The threat of malpractice further intensifies this
tendency.
Absent incentives to the contrary, physicians will continue to seek
more information than they need in many cases to do their work, thus
continuing the strong upward pressure on costs. What might help develop
counter pressures? One answer is for the profession to begin to define
practice guidelines more carefully and more extensively. Development of
such guidelines by acknowledged leaders could interact in a potentially
useful way with education and feedback. Appropriateness of deviation
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f ram the guidelines would be judged by peers. This device would not
remove clinical uncertainty, but would help the individual physician
judge what const itutes sound medical practice in particular cases.
Development of practice guidelines is fraught with problems, to be
sure. But a variety of developmental ef forts are currently underway, and
they are likely to increase. Creation of the DRGs required a similar
ef fort, and institutional management pressures will encourage similar
activities. Thus, there appears to be a convergence of forces moving in
the direction of the establishment of practice guidelines. These
guidelines could influence physician behavior positively if developed and
implemented properly. That is the policy challenge.
Environmental Changes
There is no need here to rehearse the myriad changes that are taking
place in the environment of medicine.l7 Of particular interest is the
increase in the supply of physicians J the increasing application of the
logic of managerial efficiency to the work that health professionals do,
the proliferation of organizations as the shone baser for physicians, the
infusion of private capital into the health care industry, and the growth
of multi-institutional arrangements of many sorts linking previously
independent, autonomous health care providing institutions one to another.
Opinions differ on the desirability of many of these changes, a fact
which surprises no one. At least one implication of these changes,
however, is clear. The context of the practice of medicine in 1986 will
be strikingly dif ferent f ram the context only 10 years earlier. That
context will see much closer scrutiny of physicians' work at a very micro
level, greatly increased pressures to keep costs down, much less solo
practice, and much more Corporate medicine.~18
It would take considerable time to do full justice to the
implications of the changing environment for patterns of physician
behavior. For present purposes, I would like to make only two points.
First, most physicians are well aware of the fact that change is in the
wind and that their lives will be affected by the shape of these
changes. This awareness will produce a mixture of anxiety, anger,
withdrawal, hostility and enthusiastic participation from the profession,
whose members hardly speak with one voice. Second, whatever policy
changes are contemplated should be based on emerging realities rather
than outdated models. At some point, the solo practitioner will be
exceptional. Like it or not, organized settings will be statistically
the most dominant employer of physician labor. This fact will provide
abundant opportunities to influence physician behavior. The challenge
will not be to find the little blue button which, when pushed, will
suddenly line up economic and non-economic influences in a sensible,
enduring fashion. The button simply does not exist and never will. The
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challenge is to use what is known about economic and non-economic
inf luences on physician behavior creatively and responsibly.
New Research Initiatives
In this final section of the paper, I would like to sketch the broad
outlines of an alternative way of looking at and doing research on
physician behavior which, if more f ully developed and seriously pursued,
might result in greater understanding of physician behavior and the
parameters that changes in policy might be expected to inf luence.
One str' king feature of much of the research on the topic is that it
is cross-sectional. Snapshots are taken, attributes of those snapshots
are correlated, and dynamic tendencies are inferred. The pitfalls of
such approaches are often acknowledged, yet alternative strategies have
seldom, to my knowledge, been pursued.
Cross-sectional correlational studies provide useful descriptive
portraits. They do not, however, enable one to determine the etiology of
observed patterns. How and why did the patterns turn out as they did,
and what implications do the answers to these questions have for how the
patterns are likely to look tomorrow? Or next year? The answers to
questions such as these are both important and elusive with present
research orientations. What might a more productive orientation look
like?
A combinat ion of introspection and even the most casual of
conversations with others strongly suggests that people have dif ferent
priorities at different times in their lives, that they are motivated by
different concerns, and that their behavior is most difficult to
understand, let alone influence, without some insight into what mix of
priorities has and has had significance for them. Should we expect
things to be any different for physicians? It is not unreasonable to
expect that physicians fresh out of training will have dif ferent
priorities and will respond to different incentives than physicians who
have been in practice for 20 years and whose children are through
college. At any given time the population of physicians includes people
who are at very dif ferent points in the development of thei r professional
careers and personal ambitions. It would be unrealistic to assume,
therefore, that this population would respond with anything 1 Ike
uniform) ty to changed incentive structures.
The research challenge is to develop a greater appreciation for the
dynamics of physician personal and career development. Are there
~typical. developmental patterns? If there are, what are their
characteristics and how can we account for differences between clusters?
What are the implications of these differences for changing behavior?
Might not different strategies be more effective for different clusters?
It is here that I return to the distinction between clinical and
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non-clinical behavior about which ~ expressed some concerns earlier in
the paper. The distinction is useful in the context of describing
research on physician behavior, the vast majority of which focuses on
clinical behavior. Both the distinction and the focus, however, tend to
compartmentalize artifically the life of the physician. As all of us,
the physician may play many roles: wage-earner; spouse; parent;
homeowner; politician; friend; social critic; taxpayer; investor. The
list is long. The influences on behavior are multiple and often
conflicting. To focus exclusively on clinical behavior is to focus on
one arena and perhaps to ignore or underestimate the power of other
arenas and how they do or do not fit together as shapers of motivation
and behavior.
The increasing supply of physicians, the increased emphasis on
productive efficiency, and the increasingly organized character of much
of medical practice will change the way in which the physician views the
ex ist ing opportunity structure. Research and policy need to appreciate
these changes and their personal and career impl ications . ~
developmental view of the meaning and consequences of being a physician
will enhance this appreciation.
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References
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Chicago Press, 1962; R.K. Merton, G. Reader and P. Kendall, The
Student Physician. Cambridge, MA: Harvard University Press, 1957.
~ Luft, H.S., Health Maintenance Organizations: Dimensions of
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Performance. New York: John Wiley & Sons, 1981.
3. Hick, S.S., Sussman, S., Anderson-Selling, L. et al, physician
turnover in eight New England prepaid group practices: an
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4 . Estes , E. H. Jr., The behavior of heal th prof ess ionals : Impact on
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The use of ancillary services: A role for utilization reviewer
Medical Care, 20:849-861, 1982.
6. See, for exmple, Russell, L.B.
Advances and Their Diffusion. Washington, DC: Brookings, 1979.
7.
Eisenberg, J.M., Educational program to modify laboratory use by
house staff.. Journal of Medical Education, 52:578-581, 1977;
Griner, P.F. and Lipzin, B., ruse of the laboratory in a teaching
hospital. Annals of Internal Medicine, 75:157-163, 1971.
8. See, for example, Wennberg, J.E., Blowers, L., Parker, R. et al,
Changes in tonsillectomy rates associated with feedback and
review. ~ Pediatrics' 59: 821-826, 1977.
9. Dyck, F.J., Murphy, F.A., Murphy, J.K. et al, Effect of surveillance
on the number of hysterectomies in the province of Saskatchewan.
New England Journal of Medicine, 296:1326-1328, 1977.
10. Coleman, J.S., Katz, E. and Menzel, H. Medical Innovation: A
Diffusion Study. Indianapolis: Bobbs-Merill, 1966.
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OCR for page 43
11. See, for exmple, Eisenberg, J.M. Modifying physician patterns of
laboratory use. ~ in Connelly, D.P., Benson, E.S., Burke, M.~., and
Penderson, D. teds. ~ Clinical Decisions and Laboratory Use.
Minneapolis: University of Minnesota Press, 1982: 145-158.
12. Freedman, Derek, Margaret Mead and Samoa : The Making of a Myth.
Harvard University Press, 1983.
13. Bask, C. Forgive and Remember. Chicago: University of Chicago
Press, 1979; Eisenberg, J.M. Sociologic influences on
decision-making by clinicians.. Annals of Internal Medicine,
90:957-964, 1979.
14. See, for example, Greenland, P., Mushlin, A., and Griner, P.F.
Discrepancies between knowledge and use of diagnostic studies in
asymptomatic patients.. Journal of Medical Education, 54:863-869,
1979.
15. Schroeder, S.A., Kenders, K., Cooper, J.K. et al, ruse of laboratory
tests and pharmaceuticals: variation among physicians and the effect
of cost audit on subsequent use.. Journal of the American Medical
Association, 225:969-973, 1973.
16. For an application of the principle to medical practice, see Stoss,
J.K. and Bole, G.G. ~ ~ ~ ~ ~
for the primary care physician..
22:787-791, 1979.
Continuing education in rheumatoid arthritis
Arthritis and Rheumatism,
.
17. A comprehensive analysis of many of these changes can be found in
Starr, P., The Social Transformation of American Medicine, New York:
Basic Books, 1982.
18. See Kervasdoue, J., Kimerly, J. and Rodwin, V. teds. ~
Illusion. Berkeley: University of California Press, 1984.
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The End of an
Representative terms from entire chapter:
inf luence
