Treating the Whole Person

by NORA DUNNE | photography by BRUCE POWELL

Meet Jeffrey Linder, new chief of General Internal Medicine and Geriatrics

One of the most important conclusions Jeffrey Linder, ’97 MD, MPH, has drawn in his research to date is the simple fact that doctors are people, too.

That truth seems intuitive, but it has not always been obvious when investigating strategies to encourage physicians to stop prescribing unnecessary antibiotics.

“Doctors don’t always seem to respond rationally, just like everybody else,” explains Linder, Feinberg’s new chief of General Internal Medicine and Geriatrics in the Department of Medicine and the Michael A. Gertz Professor of Medicine. “If we want to change their behavior, we have to address the underlying reasons for it — the way people actually think and behave, not the way we hope they will. Wagging our finger and simply telling doctors they should stop doing something doesn’t work.”

Linder first became interested in antibiotic prescribing practices during his residency at the University of California, San Francisco (UCSF).

“A young person who was a smoker came in with a cough. My preceptor said, ‘We shouldn’t prescribe antibiotics to somebody who has acute bronchitis, but for smokers we usually do,’” Linder recalls. “And I said, ‘Why?’”

That question set Linder off on a path that he remains on today, nearly two decades later.

Leveraging Behavioral Science

Acute respiratory infections like the common cold are typically caused by viruses — not bacteria — so antibiotics won’t help. But inappropriate antibiotics aren’t just ineffective; they can also subject patients to adverse effects and promote the development of antibiotic-resistant “superbugs.” Yet research suggests that 30 to 50 percent of antibiotic prescriptions in the United States are unnecessary.

Shortly after residency, Linder answered the very question he had posed to his preceptor and published a paper showing that smokers with acute bronchitis don’t actually benefit from antibiotics any more or less than nonsmokers. He carried out several studies demonstrating that antibiotic prescribing rates are too high in general, and then pivoted his efforts to a more actionable line of inquiry: determining interventions to reduce inappropriate antibiotic prescribing.

Investigators have been trying to influence how clinicians make decisions for decades, but previous strategies — publishing clinical guidelines, educating physicians and patients, providing financial incentives — had only modest success.

“The reason doctors don’t follow guidelines about antibiotic prescribing for upper respiratory infections is not because they don’t know the science,” explains Linder’s long-time collaborator Stephen Persell, MD, MPH, associate professor of Medicine in the Division of General Internal Medicine and Geriatrics. “There are other reasons: perceived patient demand, not knowing how to approach a patient with this expectation, overestimated fear of missing pneumonia and having a bad clinical outcome. Even fatigue may drive this to a degree.”

With the understanding that physicians aren’t always prescribing antibiotics for rational reasons, Linder and his colleagues decided to use insights from behavioral science to develop interventions.

In 2014, they published a study in JAMA Internal Medicine in which clinicians signed poster-sized commitments to avoid inappropriate antibiotic prescribing. Displaying the commitments in exam rooms led to a 20 percent decrease in inappropriate prescriptions compared to a control group.

In 2016, Linder’s group published research in JAMA demonstrating similar success with two additional inventions: In one, clinicians were required to enter justifications for prescribing antibiotics into patients’ records. In the other, clinicians received emails comparing their antibiotic prescribing rates with those of “top performers,” who had the lowest rates of inappropriate prescribing.

“People are social creatures, and we respond to the influence and perceptions of our peers. That’s an underutilized facet of human psychology in changing doctors’ behavior,” Linder says. He notes that these interventions are not only effective, they’re also inexpensive to implement and broadly applicable. “We’re hoping to use some of these same techniques to address opioid prescribing and polypharmacy for the elderly.”

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Displaying poster-sized commitments led to a 20% decrease in inappropriate antibiotic prescribing.

An Alumnus Returns Home

Research is just one area of focus for Linder. He also works in the clinic at Northwestern Memorial Hospital when he’s not in the office leading the Division of General Internal Medicine and Geriatrics, a role he took on in March.

Linder’s career has come full circle with the new job: He attended Northwestern as an undergraduate student, where he met his wife, Debbie, and then earned his medical degree at Feinberg. After residency at UCSF, he completed a fellowship at Massachusetts General Hospital and received a master of public health degree from the Harvard T.H. Chan School of Public Health.

He went on to spend 15 years on the faculty at Harvard Medical School and as a general internist at Brigham and Women’s Hospital in Boston. He also directed Brigham and Women’s Primary Care Practice Based Research Network.

Now he’s back in Chicago where it all began.

“It’s been pretty cool,” Linder says with a laugh. “The city looks incredible — much better than when I was a student here 20 years ago. And Northwestern has expanded in incredible ways, too. I left right before the new hospital went up in ’99, and now the whole campus is different.”

That expansion is part of the reason Linder chose to make the move.

“The scale of Northwestern is so impressive. The challenge is pulling together as an integrated health system that does clinical care, research and education all excellently,” he explains. “I think we have fantastic potential to make that happen.”

THE CHALLENGE IS PULLING TOGETHER AS AN INTEGRATED HEALTH SYSTEM THAT DOES CLINICAL CARE, RESEARCH AND EDUCATION ALL EXCELLENTLY.

“Jeff’s recruitment followed an extensive national search, and we could not have found a better fit for General Internal Medicine and our nascent academic health network,” said Douglas Vaughan, MD, chair of Medicine and Irving S. Cutter Professor of Medicine. “I am certain that he will have an enormous impact on our primary care network as it evolves.”

The scale in Linder’s division alone is formidable: The Department of Medicine’s largest division, with about 300 faculty members, General Internal Medicine and Geriatrics has the potential to touch more students and patients than perhaps any other. Its research programs span from quality improvement and safety to use of electronic health records to reducing disparities for historically underserved communities.

“We’re all interested in delivering, and improving the way we deliver, high quality primary care,” Linder says. “From an intellectual standpoint, being a general internist can be the most challenging, because we’re taking care of the whole person, through thick and thin.”

He hopes to instill his excitement about general internal medicine to the next generation. “There’s nothing more rewarding, from the patient contact you get, to the unceasing variety,” he says. “As a student here myself, I got great clinical training and exposure to think hard about what we do every day, and the desire to see what we can do to make it better.”

“Jeff brings many skills and talents to the Division of General Internal Medicine and Geriatrics: the ability to critically and thoughtfully appraise the healthcare delivery system, the capability to develop relevant change strategies to improve healthcare, and the leadership needed to conduct vigorous practice-based research to test new approaches,” Persell says.

“I am thrilled to work with him at Northwestern.” Linder has already started a study at Northwestern to measure antibiotic prescribing practices at his new health system, and he won’t soon give up his interest in respiratory infections.

“American healthcare doesn’t do a great job treating these very common, simple infections,” he says. “Yet we have this expectation of doing ‘precision medicine’ very soon. We need to pay attention and get the simple things right, too.”