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Clinical Inertia
- Lawrence S. Phillips, MD;
- Joyce P. Doyle, MD; and
- William T. Branch, Jr., MD
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•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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IN RESPONSE:
Our paper was prompted by observations that although many patients have chronic disorders that confer increased morbidity and mortality (1), they are often not managed to achieve the maximum potential benefit of therapy, despite strong evidence that treatment is beneficial and cost-effective and carries little major risk. In this context, Dr. Steinberg properly emphasizes that submaximal intensity of management may reflect the explicit wish of the patient. However, since national standards for care can be met in some real-world practice settings (2, 3), failure to meet such targets in other settings must be attributed either to patient self-selection bias or to insufficient emphasis by the physician: clinical inertia. Since emphasis on overcoming clinical inertia improved diabetes outcomes in our own practice without much in the way of patient objections or complications from hypoglycemia (3, 4), we believe that clinical inertia is often the limiting problem.
We agree that if the primary goal is no hypoglycemia or orthostatic hypotension, then glucose and blood pressure targets will often not be met. However, since such a posture is usually unreasonable, the question then becomes how to improve management. We must disabuse physicians of the notion that disorders are being treated adequately if they are treated at all; the combination of “suboptimal treatment” and “no complaints” may still be much less than what could be achieved in the same setting with little further increase in cost, inconvenience, or side effects. The responsibility for recommending intensification of management is the physician's, since only he or she can be fully informed about benefits and risks. We suspect that few physicians ask their patients specifically whether they would prefer a higher risk for stroke rather than a higher risk for orthostasis. We believe that rectifying the problem will require physician education in the details of treating to target, systems to show physicians exactly what their care consists of (since overestimation of performance is common [5]), and suggestions about ways to improve.
We agree with Dr. Wofford that periodic evaluations of medications are important. However, many patients will eventually need to be treated for combinations of diabetes and hypertension and dyslipidemia and heart failure and osteoporosis. Since management of these disorders is both evidence based and cost-effective, stopping appropriate therapy should not usually be considered until very late in life. Thus, for most patient encounters, the focus should properly be on doing more rather than doing less.
Lawrence S. Phillips, MD
Joyce P. Doyle, MD
William T. Branch Jr., MD
Emory University
Atlanta, GA 30322
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
