PHILADELPHIA — In the fight against a nationwide prescription opioid abuse epidemic, Penn Medicine researchers are using storytelling to help doctors recall important, potentially lifesaving national guidelines on how to prescribe these medications.
The story they are testing begins with a man named Frank, a friendly, middle-aged man who came to a crowded emergency room complaining of back pain that he said didn’t get better despite use of hot packs, Advil, and massages from his wife. His doctor is unable to access her state’s prescription drug monitoring program to check if he already had prescriptions for pain pills, but follows recommended guidelines for giving him low doses of opioids for a short time, until he could visit his regular doctor. Only later did she learn he had been visiting several other EDs in recent months, walking away with Percocet from each one – a red flag that he may be misusing these opioid prescriptions.
The team of researchers from the Department of Emergency Medicine at the Perelman School of Medicine found that physicians who heard this narrative, or story, about opioid guidelines were more likely to recall the guideline content after an hour than those who just heard a summary of the guidelines. The new study is published online ahead of print in the journal Academic Emergency Medicine.
Opioid overdose is the second leading cause of unintentional injury death in the U.S., and many of these fatalities can be attributed to patients taking too much a legally prescribed pain medication. Nearly half of patients presenting to an emergency department (ED) have painful conditions, yet emergency patients are also considered at high risk for opioid abuse. To deliver patient-centered care, emergency physicians are often challenged to identify – during only brief interactions – the best pain regimens to prescribe. In order to better help clinicians identify patients who most need prescriptions, the American College of Emergency Physicians (ACEP) published an evidence-based clinical policy in October 2012 outlining optimal pain management in the ED.
“Evidence-based guidelines can be valuable tools for providers and incorporate the best clinical research findings to help direct appropriate care for patients. The problem is, many physicians don’t readily adopt guidelines, creating an unfortunate barrier between rigorous medical research and the day-to-day practice of medicine,” said senior study author Zachary Meisel, MD, MPH, MSc, assistant professor of Emergency Medicine in the Center for Emergency Care Policy Research and a senior fellow at the Leonard Davis Institute of Economics at Penn. “From previous research, we know that narratives in medicine serve as a powerful tool for translating and communicating complex ideas to patients, so we wanted to know if this same approach could help doctors better recall and relate crucial care-related protocols when it comes to prescription opioids.”
To test this innovative approach, the research team conducted a prospective, randomized controlled experiment to compare whether a short narrative versus a summary of clinical guidelines promoted short-term recall of six themes contained in the ACEP opioid guideline with 82 emergency medicine clinicians from across Philadelphia.
The experiment was modeled after the free-recall test, an established technique in studies of memory. Emergency physicians were randomized to read either a summary of the guideline or a narrative. The fictional narrative was constructed to match the summary in content and length. One hour after reading the text, participants listed all content that they could recall.
“In medical school we are taught, and often rightly so, to be wary of anecdote when making decisions about patient care. So we didn’t know what we would find. But we believe that doctors are people too—so why couldn’t stories be helpful for doctors who need to integrate and use evidence-based information all the time?” asked Meisel.
Physicians exposed to the narrative about opioid guidelines were more likely to recall specific components of the guideline content at one hour than those exposed to a summary of the guidelines. For some components, the increased rate of recall among the story group was as high as three times the rate of the summary. For three of the six themes, the proportion of responses that recalled the theme was significantly greater in the narrative arm compared to the summary arm, with the differences ranging from 20 to 51 percent. Additionally, the research team found that in the guideline summary arm, 54 percent of responses were found to contain falsely recalled or extraneous information versus 21 percent of responses in the narrative arm.
“While this study was not designed to detect whether exposure to narratives improved actual adoption of the guidelines, it did demonstrate that evidence-based narratives may enhance the memorability of guideline recommendations, which may lead to a new approach in tackling a dire and perplexing public health crisis in our country,” said Meisel.
To address the question of whether the narratives actually encouraged adoption of the guidelines, Meisel and colleagues at Penn are currently studying a national sample of emergency physicians, funded by the Agency for Healthcare Research and Quality (AHRQ), to determine if stories might change emergency room physicians’ information seeking behavior around the decision to prescribe opioid painkillers.
Other Penn Medicine study authors include lead study author Austin S. Kilaru, Jeanmarie Perrone, MD, Catherine L. Auriemma, Frances S. Shofer, PhD, and Frances K. Barg, PhD.
The research was supported in part by an NIH career development award in comparative effectiveness research (ZFM) (KM1 CA156715-01). Additional support was provided by an AHRQ patient-centered outcomes research and dissemination award (SFM) (R18 HS021956-01).
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