Exemplary Report and Missed Opportunities: The influence of worldview and the difficulty of overcoming our training

In reading the recent report by Kirkman et al. (1), I was simultaneously impressed and troubled. I was impressed by the attempt of this important work to improve the quality of care among seven rural primary care practices. Their detailed reporting of both initial and long-term results, and of both quality of care and physiological outcomes, was impressive. Especially noteworthy was their inclusion of longer-term, 2-year data, which are seldom reported. Their candor in discussing the failure to maintain the initial performance improvements, as well as their insightful discussion of potential reasons for these findings and the characteristics of systems that successfully improve quality, are refreshing and informative.

I was troubled, however, by the findings concerning the smoking cessation counseling index. I was struck by the validity of the observations of Kuhn (2) and Anderson (3), especially pertaining to diabetes management, that one’s worldview determines how problems are identified and addressed. The authors report that they dropped any further consideration of improvement on the smoking cessation measure due to the very low baseline level of documentation of smoking status. I wonder, if this had been the case with low levels of documentation of A1C status, would the authors have made a similar decision? Instead, they would likely have used this as a rationale for redoubling their efforts to regularly collect and intervene on this measure. The dropping of smoking documentation and counseling was especially disappointing given the unquestioned clinical importance of smoking status and the availability of very cost-effective primary care–based interventions to improve smoking assessment and counseling (4).

I cannot help but speculate whether the prevailing biomedical perspective in which many of us have been trained (and which still largely dominates diabetes care [3]) did not influence this decision. Another finding reported in the Kirkman et al. (1) article further heightened this impression: the patient education program did not impact many of the intended patients in these practices. It would seem to be a well-integrated clinical activity to have a patient education program that was tied to the quality issues that the providers were focusing on. However, there are two major concerns: 1) the decision to offer group-based educational sessions on a predetermined topic, rather than problem-based learning and self-management sessions on topics of interest and concern to patients (5,6), and 2) most diabetes educators have been trained to offer such group sessions and continue to do so, despite strong evidence that even under the best conditions, only a minority of patients will attend such sessions, and this modality often fails to reach those who are most in need of such assistance. If instead an approach had been used that focused on the ultimate panel or population-based impact (7) (e.g., www.re-aim.org), and on problem-based learning that was focused on issues of concern to patients, it is likely that alternative approaches, such as nurse-based self-management training or proactive phone counseling, would have been selected.

My purpose is not to criticize these investigators, who are leaders in their field and have provided an important report that focuses on many of the complex issues involved in translating research into practice. Rather, the point is that we all need to “think differently” and to ask hard questions of ourselves when faced with such translation challenges. The models and methods in which most of us have been trained have been partial causes of our current dilemma. As Einstein is reported to have said, “The significant problems we face cannot be resolved by thinking at the same level that created the problems.”

It is hoped that evidence-based guidelines that place equal emphasis on important patient self-management behaviors as on laboratory assays and checklists and flow diagrams, such as those being developed by the Evidence-Based Behavioral Medicine Committee of the Society of Behavioral Medicine (8), will help us to think differently, to ask the hard translation questions, and to experiment with the innovations necessary to close the quality chasm.