Why Physicians Don’t Always Follow Best Practices

What to do for someone with swimmer’s ear is, by now, very clear: Use antibiotic eardrops. The issue has been settled in the literature and in expert reviews of the evidence. Oral antibiotics not only don’t tend to work; they promote antibiotic resistance, too (Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24).

But, frequently, this is not done. “I cannot tell you how many people have been put on several different oral antibiotics as first-line medical intervention,” said Wendy Stern, MD, a physician at Southcoast Hospital Group in Dartmouth, Mass., and immediate past chair of the board of governors of the American Academy of Otolaryngology-Head and Neck Surgery. “It comes down to pressure not to refer to the specialist. Many patients are treated at walk-in and urgent-care centers and by mid-level providers and physicians who may not know the guidelines. By the time they come to us they have a significant problem, where if they had been treated with antibiotic ear drops they probably would have gotten better very quickly.”

Many of these patients experience compromised hearing and miss work or school due to severe pain. Many of these patients end up in severe pain, can’t go to work, or can’t even hear with the infected ear. Often the ear canal is so swollen by the time we see them we’re at the point of putting wicks in their ears,” Dr. Stern said. “Sometimes it’s complicated by a fungal infection on top of a bacterial infection. It’s a whole variety of things.”

Dr. Stern, now working on guidelines on the adult neck mass, emphasized she was speaking only for herself and was not representing the academy.

Even in cases where the evidence has made it obvious what is optimal, best practices for otolaryngology care are often not followed. And not just by primary-care or community physicians. A noteworthy percentage of otolaryngologists don’t follow guidelines, either, studies have found, although it is hard to get solid data on guideline-adherence across the field.

“Guidelines are followed, but I think inconsistently,” said David Tunkel, MD, chair of pediatric otolaryngology at Johns Hopkins and the current chair of the AAO-HNS guidelines task force.

A new study on compliance with AAO-HNS sudden sensorineural hearing loss guidelines, done through the CHEER network (Creating Healthcare Excellence through Education and Research), found that otolaryngologists follow many of the guideline recommendations at least 90% of the time. Among non-otolaryngologists, compliance was below 45% for three of the items. The researchers concluded that, while there is high compliance on some items, “there is significant room for improvement.”