My best boss, Al, once proposed to me his theory of scientific change. All the guys who were wrong had to die before the bad science died. Here’s a great example with physicians and colonoscopies.
Researchers did a database search of VA records to see how often physicians there violated recommended use of colonoscopy in their practice. Since this is the VA, financial incentives for nonstandard practice do not exist. Physicians do this because they can and they want to. So. How many conduct this procedure even when it goes against national and association standards and practices?
The percentage of non-adherent physician recommendations for repeat colonoscopy was as low as 3% and as high as 80% of colonoscopies across medical centers (Table 3). Overall, 35.8% of the physician recommendations for the interval until next colonoscopy were non-adherent (Table 3).
Even removing the financial incentive that often drives physician behavior, especially on screening tests, nearly 1 in 3 still violate recommended use of colonoscopy. That doesn’t mean the procedure is harmful, wrong, or dangerous, just that it was done when there was no indication for it or done sooner than advised or for mere surveillance reasons. The largest concerns with this kind of non-compliance with Uncle Norm are: 1) still financial because you are spending money for nothing, 2) fear and worry from the inevitable false positive test, and 3) the very rare fatality as the procedure goes bad and the patient dies only as a result of the test.
Consider the persuasion implications of this single observation database study. We are dealing with Other Guys who are among the smartest, best trained, and wealthiest people in the United States. These guys are supposed to be the best of the best. As part of achieving this elite status, these Other Guys are supposed to maintain an elite effort where they continually seek, nay, demand, perfection from themselves in the pursuit of their elite knowledge and skill. And, yet, 1 in 3 blow off the recommendations of their peers for a simple activity like a screening test. Imagine what would happen to garages that are licensed to perform state car inspections who engaged the services of 1 in 3 mechanics who blew off the recommendations for inspecting vehicles.
In this case it appears that Al was right: They all have to die before the standard becomes Uncle Norm.
Johnson MR et al. Physician nonadherence to colonoscopy interval guidelines in the Veterans Affairs healthcare system. Gastroenterology 2015 Jun 26; [e-pub].