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Spring 2013 issue (pdf)

How academic detailing improves patient care

New data, new drugs, new technologies, new knowledge – each has a bearing on the quality of patient care, and each can advance in rapid, relentless fashion. An innovative method of educational outreach called academic detailing is gaining momentum as an effective approach to helping practicing clinicians stay current with the constantly evolving information.

“The goal of academic detailing is to promote evidence-based care,” said Rupin Thakkar, MD ’03. “It can be applied to any clinical topic in which there is a gap between best practice and current practice.”

Pediatrician Rupin Thakkar, MD ’03, an advocate for academic detailing, enjoys a lighthearted moment with a patient.

Pediatrician Rupin Thakkar, MD ’03, an advocate for academic detailing, enjoys a lighthearted moment with a patient.

Dr. Thakkar is a pediatrician at the Children’s Clinic of South Snohomish County in Edmonds, Wash. He has been active in health policy and legislative advocacy since he began his medical training, and academic detailing is an asset in his efforts to make impartial information more accessible to physicians in a climate where biased or outdated information can be common.

Time constraints are among the biggest obstacles to keeping up to date with the latest evidence, since doing so requires consuming a heroic amount of research literature. Academic detailers prioritize and synthesize this information and communicate personally with providers in practice.

“Academic detailing programs provide objective clinical information in an engaging format,” Dr. Thakkar said. “Physicians have the opportunity to interact one-on-one with experts who are trained to present evidence-based clinical data in a relevant and meaningful way to clinicians.”

Although conceptually, academic detailing can be used to convey non-commercial information on just about any conceivable topic, the most prevalent application is to provide impartial information about prescription medication. Pharmaceutical representatives often use detailing to promote specific brand drugs to prescribing physicians, but the information, by its nature, has a commercial objective. Doctors really need evidence-based comparisons on the safety, efficacy and cost of medications within classes of drugs, Dr. Thakkar said.

Toward this end, Dr. Thakkar, and another Medical College of Wisconsin alumnus, family physician Jeff Huebner, MD ’01, co-founded the Washington Coalition for Prescribing Integrity (WCPI) with a grant from the Pew Charitable Trusts’ Prescription Project. Both Dr. Thakkar and Dr. Huebner were founding members of the National Physicians Alliance, an organization committed to professional integrity, and have been engaged in legislative advocacy at the state level to regulate pharmaceutical marketing practices.

One of the primary activities of the WCPI has been to promote educational opportunities for health care providers that foster evidence-based prescribing. Prescriber education was, in fact, the impetus for academic detailing, the roots of which stretch back about 30 years. More recently, however, its pioneers and contemporaries have convened around an initiative funded by the Agency for Healthcare Research and Quality and housed at Brigham and Women’s Hospital and Harvard Medical School. The National Resource Center for Academic Detailing (NaRCAD) promotes the use of evidence-based medicine by supporting the establishment and improvement of academic detailing programs.

David Lehmann, MD ’87, PharmD

David Lehmann, MD ’87, PharmD

David Lehmann, MD ’87, PharmD, is directing and collaborating on an ambitious health care improvement project that incorporates academic detailing more broadly for provider education.

It is an opportunity to demonstrate the effectiveness of the SUNY-DoH Collaborative for Medication Use, which he helps facilitate between the State University of New York system and the New York Department of Health. Dr. Lehmann is Professor of Medicine and Pharmacology at SUNY Upstate Medical University. His clinical experience, background as a clinical pharmacologist and his longstanding relationship with the Department of Health are utilized in the collaborative’s efforts to improve drug safety and therapeutics.

“Nearly my entire role through the collaborative is acting as a champion for pharmacists, giving them more visibility and contact with physicians and more respect,” Dr. Lehmann said.

Prescriber education is a key component of the collaborative, and academic detailing is a component within that mission. To address a particular medication use issue relevant to the public health, pharmacy experts within the collaborative develop a white paper on the specific  topic. This is then refined by medical experts, approved by the Department of Health and then synthesized into best practice points that the academic detailer will impart when visiting prescribers.

“The academic detailers are the human face, and providers come to see the detailers as their own PharmD in their pocket,” he said. “It circumvents the activities of the industry drug detailers. They use the same techniques from a social standpoint, but our information is evidence-based and nonbiased.”

The detailers’ messages are further reinforced by software tools that are free to anyone who sees Medicaid patients in the state of New York. The Web modules include an integrated formulary, drug information response postings and interactive treatment algorithms.

The effectiveness of the program is illustrated in an initial case study of palivizumab utilization. The collaborative was able to identify about 20 percent of prescribers across 15-20 practices whose utilization of the high-cost drug used to prevent RSV did not conform to best practices. The team developed its education materials and algorithms and deployed its pharmD detailers to those practices.

The program’s success was evidenced by a health care cost savings of more than $20 million, or 31 percent, in 2009-2010, the year following the academic detailing initiative.

“Doctors want to do the right thing and treat their patient right,” Dr. Lehmann said. “Not all prescribers keep up to date on their data and evidence, and they know they’ve fallen behind or they’re using anecdotal information. But if you show them what their patients are doing vs. the standards, and what the competition down the road is doing, things get changed quickly. And I can’t undersell the usefulness of supporting the detailing with technology.”

A palliative care team at the Medical College of Wisconsin is using technology in another way—to deliver academic detailing-based resident education—and a recent study supported its value.

Sean Marks, MD ’04, GME ’08, talks with residents about palliative care at MCW.

Sean Marks, MD ’04, GME ’08, talks with residents about palliative care at MCW.

Sean Marks, MD ’04, GME ’08, Assistant Professor of Medicine (Hematology/Oncology), and collaborators at the University of Pittsburgh and the University of Minnesota published “The Educational Impact of Weekly E-mailed Fast Facts and Concepts” in the Journal of Palliative Medicine in 2011. Dr. Marks describes Fast Facts as one-page summaries that capture evidence-based literature reviews on key palliative care topics. There are about 250 Fast Facts papers in use throughout and beyond the palliative care community in more than 100 different countries.

“We consider it academic detailing because a resident who has questions can access this resource for quick, reliable information,” Dr. Marks said. “As palliative care doctors, we might also print Fast Facts on a particular topic and attach it to a patient’s chart, so it becomes patient care-specific.”

The study authors hypothesized that if residents received Fast Facts in a weekly email, like a virtual academic detailing visit, they would benefit from an improved knowledge base and confidence. Residents at the Medical College of Wisconsin and at Pittsburgh were randomized into two groups. One group received the Fast Facts emails; the others were simply told about Fast Facts.

The study showed that residents who received the emails had “significant increases in medical knowledge and self-reported preparedness on symptom management skills.” They were a great resource for reinforcing foundational knowledge, such as how to manage pain medication or managing cough, Dr. Marks said. The method was not helpful for improving communications-based skills, however, such as planning end-of-life care with families.

The academic detailing approach is effective because it targets clinician behavior in a way didactic teaching may not, Dr. Marks said.

“To really lead to changed behavior, you need targeted, repeated exposures,” he said. “Changing physician behavior works toward the larger goal of improving patient care and experience.”

For this reason, academic detailing holds great potential. Alumni noted they have begun seeing academic detailing employed effectively for various clinical topics, including smoking cessation, cancer screening, developmental delays screening and MRI utilization.


Detailing resident education

In addition to e-mailed Fast Facts, palliative care faculty at the Medical College of Wisconsin use the one-page, peer-reviewed summaries in an interactive manner further inspired by academic detailing.

Twice a week, the palliative care team selects a specific Fast Facts sheet pertaining to a specific palliative care issue. They then pick a rotator on the palliative care service (often a medical student or resident physician) to lead a 15-minute discussion on that Fast Fact topic. The rotator then opens the discussion to questions with staff doctors on hand to provide additional depth of information or clarification.

“The face-to-face interaction reinforces the information and uses Fast Facts as a launching point,” said Sean Marks, MD ’04, GME ’08, Assistant Professor of Medicine (Hematology/Oncology). “We try to meet learners where they’re at, determine where there are knowledge gaps, and design evidence-based tools that address those areas.”

Attaching the Fast Facts to a chart for relevant patient encounters is a particularly effective teaching opportunity.

“If we can do it ‘just in time,’ that is most effective,” he said. “We can provide education at the moment the resident is seeing a patient and wondering, for example, How do I adjust these pain medications? Then the resident can incorporate that knowledge on pain management into the care of the patient.”


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