“To him who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his cup of joy is full when the results of his studies immediately find practical applications.”
Henry “Moon” Mullins was the founding chair of the department of which I am now the Chairman. He trained at Tulane (as did I) and was in private practice for about 20 years in Fairhope Alabama when he got a call from Fred Whiddon, the founding President of the University of South Alabama. Dr Whiddon wanted to see if he would consider leaving his practice to create a Department of Family Medicine in Mobile, which he did. When I met him, in 1991, he was in 64 and had just completed a sabbatical studying medical infomatics at the National Library of Medicine. As a resident and later as junior faculty, I would have long discussions with Moon about how to get “docs” to practice based on best practices rather than using techniques and information obtained during training (regardless of how many years ago) or for better or worse, from pharmaceutical reps.
In that discussion, we would often mention the problem of diffusion. From an article in 2006:
Studies of dissemination of evidence-based guidelines (aka, consensus statements) suggest that awareness varies widely across medical subspecialty, with awareness ranging from as low as 20% among cardiac surgeons to 90% to 95% among obstetricians.17 The dissemination gap for clinical research also has a time component. A review suggested that it took an average of 17 years for 14% of original (i.e., discovery) research to be integrated into physician practice.
17 years seemed to me like a very long time. Why so long? Many people my age have stained teeth from tetracycline, a miracle antibiotic that was introduced in the 1960s. For that antibiotic, it wasn’t 17 years but 17 months before 90% of physicians were using it. The combination of its remarkable effectiveness and peer pressure from early adopter colleagues was enough to overcome physician inertia. Many discoveries though, such as the life saving effect of beta-blockers for a year following a heart attack, are not given to all eligible patients even today, more than 20 years after the data was definitive.
Today, appropriate beta blocker use varies regionally from 68% to 92%. What is surprising is the factor that predicts the best who will get the appropriate medication: Tractor use in 1940.
The introduction of hybrid corn in the 1930s and the introduction of tractors in farming was not via a disruptive innovation model. The first states to have over 10% of farmers planting high yield corn and using tractors? Illinois and Iowa in 1935. The last states (1948)? Alabama and Georgia. Being a “late adopter” state for these technologies correlates strongly with being a late adopter for the use of beta-blockers after a heart attack. For example, Alabama was last to adopt tractors and to adopt beta blockers.
What set apart the early adopters? One of the factors is having folks (farmers and doctors) talk to each other in informal settings. We late adopters need to pay more attention to having quality information exchange among health professionals. Another is that, educationally, a rising tide floats all boats. A better educated populace demands better care. Lastly, innovation likely didn’t occur because it was more profitable to wait. Second-mover advantage, risk aversion, and uncertainty are powerful de-motivators. We need to change the incentives such that physician are paid to do the right thing.
Moon is now 86 and calls the department every now and again to check on us. As a department, we continue to work on ways to encourage physicians in Alabama to “do the right thing” and overcome our historic tractor disadvantage.
Thanks, Moon, for starting us on this journey.