Valuing Knowledge and the Knowledge of Values: Understanding Guideline‐ Incongruent Prescribing

A extensive number of practice guidelines have been published and promulgated to guide the behavior of health care providers. Yet, the use of drugs in a guideline-incongruent manner continues to be an issue, and the traditional research frontier seems only capable of making small gains in this area. To better understand why we are observing disappointing drug utilization practices, we need to challenge the belief that noncompliance with optimal practices simply reflects a lack of informed judgment that can be corrected by educational interventions. A number of studies have demonstrated that a deficit in knowledge is not the only factor leading to guideline-incongruent prescribing. More than two decades ago, Alfred Bandura introduced self-efficacy as a unifying theory of behavior change. Self-efficacy is the self-perception that an individual has the ability to change his or her behavior. High self-efficacy is present when (1) an individual believes that a new behavior is worthwhile, (2) he or she has confidence in the ability to perform the new behavior, and (3) a reward is anticipated (outcome efficacy). The presence of these three features increases the likelihood that the behavior will be adopted. From this theory, one can see that knowledge alone is insufficient to change behavior, yet most interventions to improve physician prescribing behaviors focus on education as a means to achieving that goal. The dissemination of prescribing guidelines and continuing education events can be viewed as methods for bringing about behavior change through improving knowledge. Incorporating the self-efficacy model into our understanding of guideline-incongruent prescribing requires an appreciation of values since it is the value placed on a behavior that will influence whether it will occur. Policy makers and educators need to understand the nature of these value systems. Self-efficacy theory would suggest that we must start thinking of guideline usage as an issue of knowledge and values. The interaction between physician knowledge and values creates a much more complex model of behavior than the traditional model where physician knowledge has been heralded as the overriding determinant of physician behavior. Consider the following scenarios, where despite physicians being aware of the requisite medical knowledge, the clinical ideal is not consistently achieved: