What Would You Do, Doc?
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV. Dr. Gupta reports no financial relationship relevant to this field of study.
Synopsis: Physicians often do not choose the same clinical treatments for themselves as they would recommend to their patients.
Source: Ubel PA, et al. Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med 2011; 171:630-634.
In clinical practice, one of the most challenging situations arises when our patients facing difficult decisions themselves ask the physician, "What would you do, doc?" From the patient's perspective, it is only natural when faced with such often complex treatment decisions to turn to the one person who has already guided them so far the physician. Conversely, most physicians are pleased to discuss treatment options in detail along with the available evidence and address the patient's concerns. However, most still stop short of making a clear recommendation for a particular treatment option. Most physicians understand that their recommendations can lead people to make decisions that could go against what the patient may otherwise prefer.1 Therefore, understanding that their advice might influence patients' decisions away from the preferred treatment option, physicians often encourage their patients to identify their own preferences and help to find the treatment option most consistent with them.2 Yet, as more treatment options become available, the decision matrix becomes more complex resulting in more dependence on the physician to assist in decision making.3,4 In the face of this rising dependence on the physician in the shared decision-making process, little is known about when physicians do make such a recommendation, what shapes this advice? And, does the very act of making such a recommendation influence how physicians judge treatments?
In their study, Ubel et al tested whether making a recommendation changes the way that physicians think about medical decisions. The researchers conducted two randomized experiments in which they provided two alternatives each and asked physicians to decide which treatment they would choose if they themselves were the patient or which treatment they would recommend to a patient facing the same decision. In the first experiment, 500 physicians were asked to imagine that either they or one of their patients had just received a diagnosis of colon cancer and faced a choice of one of two operations to treat the cancer. Both surgeries cured the colon cancer in 80% of patients, however, one surgery had a higher mortality rate, but fewer adverse effects, whereas the second surgery had a lower mortality rate but a small percentage of patients experienced colostomy, chronic diarrhea, intermittent bowel obstruction, or a wound infection. This choice involved a trade-off between the risk of death and the chance of one of the four surgical complications mentioned. Of the 242 physicians who responded to the questionnaire, 37.8% of physicians chose the surgical procedure with a higher rate of death, but a lower rate of adverse effects. In comparison, when asked to make a recommendation for a patient, only 24.5% of physicians chose this option.
The second experiment involved surveying 1,600 physicians about a new strain of avian influenza that had just arrived in the United States. One group of physicians was asked to imagine that they had been infected and the other group was asked to imagine that his or her patient was infected. Without the treatment (immunoglobulin therapy), infected patients would have a 10% death rate and a 30% hospitalization rate with an average stay of 1 week. With treatment, the rate of adverse events would be reduced by half; however, it would also cause death in 1% of patients and permanent neurological paralysis in 4% of patients. Of the 698 physicians who responded, 62.9% chose to forgo immunoglobulin treatment when imagining they had been infected to avoid its adverse effects. However, when imagining that a patient had been infected, only 48.5% of physicians recommended not getting the treatment. Further analysis demonstrated that choice was not associated with respondent age, sex, or volume of patient care.
Overall, physicians were more likely to choose the treatment with the greatest chance of survival when recommending a treatment for their patients, but more likely to choose the treatment with the lowest risk of side effects or complications for themselves.
Commentary
While this study doesn't suggest that physicians always make better decisions for others than they would make for themselves or vice versa, it is an interesting insight into the physicians' ability to make a distinction when making treatment recommendations vs when making a treatment decision for themselves. Perhaps some of this can be explained by the fact that we are taught not to make value judgment for others in the process of rendering care. Therefore, we may not be able to fully engage the same criteria and biases for others (patients) as we would for ourselves. In other words, physicians in this study may have been able to make more candid treatment decisions for themselves since they did not feel the need or the fear to explain those decisions to anyone. However, by the same argument, the question then arises whether the need to defend recommendations for patients interferes with certain inherent biases in the physicians' ability to make guileless treatment recommendations. It is critical to pursue more research in this field to learn what biases play a role when physicians and other health care professionals make recommendations. Understanding the roots of such biases can help physicians and patients make decisions that best reflect each patient's values regarding his or her medical condition. After all, it's not about making the right or the wrong treatment recommendation, it's about making the best decision for each individual patient!
References
1. Gurmankin AD, et al. The role of physicians' recommendations in medical treatment decisions. Med Decis Making 2002;22:262-271.
2. Mendel R, et al. Do physicians' recommendations pull patients away from their preferred treatment options? Health Expect 2011 Feb 16. doi: 10.1111/j.1369-7625.2010.00658.x. [Epub ahead of print].
3. Kaplan RM, Frosch DL. Shared decision making in clinical medicine: Past research and future directions. Annu Rev Clin Psychol 2005;1:525-556.
4. Elkin EB, et al. Desire for information and involvement in treatment decisions: Elderly cancer patients' preferences and their physicians' perceptions. J Clin Oncol 2007;25:5275-5280.
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