Barriers to the integration of new evidence in medicine: The importance of context

In the current issue of Arthritis Care & Research, the study by Pradhan and colleagues (1) suggests that training in the skill of mindfulness (what they and others have defined as “moment-to-moment, non-judgmental awareness” [2]) may benefit patients with rheumatoid arthritis (RA). While the investigators failed to find significant changes in RA disease activity as measured by the Disease Activity Score 28-joint assessment, the 35% reduction in psychological distress at 6-month followup is not insignificant, particularly given the considerable mood disturbance and psychological effects that can accompany pain-related conditions such as arthritis. Although the study was likely underpowered and limited by the lack of an active control condition, the fact that positive changes were observed at 6 months (and were, in fact, more pronounced than those seen at the postintervention assessment) suggests that the intervention, and not merely some nonspecific (placebo/ expectancy) factor, was responsible for the symptom improvements observed. These positive changes in mood and psychological wellbeing are consistent with data from other studies of the potential value of mindfulness-based interventions to reduce stress and help patients cope more effectively with the mental, emotional, and physical challenges that frequently accompany chronic health conditions (3). Pradhan and colleagues’ findings also lend support to the growing evidence base encouraging the use of an array of psychological interventions to improve mood and quality of life in patients with arthritis and other pain-related conditions (4,5). For example, a meta-analysis published in 2002 (4) found that the adjunctive use of psychological interventions (such as multimodal cognitive-behavioral interventions that teach skills for stress management, pain coping, and relaxation) improves clinical outcomes such as pain, function, and quality of life in patients with RA. Similar data exist for osteoarthritis, indicating that psychosocial behaviorally based interventions consistently improve treatment outcomes (6). In spite of such findings and the growing epidemiologic, basic science, and clinical evidence base pointing to the complex interplay of biologic, psychological, and social factors’ influence upon human physiology and health (7– 9), research suggests that psychosocial factors continue to be overlooked or frequently missed in clinical encounters (10,11), and as a rule continue to be underemphasized in medical education (12,13). Studies also suggest that empirically supported behavioral/mind-body interventions for such common health problems as pain and insomnia are used by only a minority of patients with these conditions (14). An example of this apparent disconnect between the evidence base (linking mental-emotional factors and physical health outcomes, including arthritis) and the actual attitude and practice patterns of physicians can be seen in some recent work carried out by a research group of which I am a member. In a national survey of physicians in primary care and several selected primary care specialties, we found that only 20% of physicians and 12% of rheumatologists indicated that the inclusion of psychosocial/ mind-body methods would lead to significant improvements in patients with arthritis (15). Data from a national survey of interns and residents parallel these findings, with only 23% stating that such methods would lead to significant improvement in arthritis treatment (12). In light of such findings, the obvious question arises: why, particularly in an era of so-called evidence-based medicine, is this growing evidence base that points to the clinical utility of behavioral/mind-body therapies and the influence of psychological factors on human health and physiology failing to be integrated into the way medicine is being taught and practiced? It is important to point out that despite the belief that medical practice should be grounded in solid scientific evidence, the generation of such evidence, while often necessary, is frequently insufficient to actually change clinical practice. In an effort to shed light on the possible factors that influence whether or not physicians adopt new knowledge, Cabana et al (16) reviewed 76 studies that examined obstacles to clinical guideline adherence. In their review, factors impacting physicians’ attitudes included a lack of agreement regarding the clinical guideJohn A. Astin, PhD: California Pacific Medical Center, San Francisco. Address correspondence to John A. Astin, PhD, California Pacific Medical Center, 2200 Webster Street, Room 503, San Francisco, CA 94115. E-mail: john@integrativearts.com. Submitted for publication May 14, 2007; accepted in revised form May 28, 2007. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 57, No. 7, October 15, 2007, pp 1116–1118 DOI 10.1002/art.23004 © 2007, American College of Rheumatology