Tuesday, April 12, 2011

Physicians Recommend Different Treatments for Patients Than They Would Choose for Themselves


Article from the annals of internal medicine. Very interestingly  the conclusion is that physicians opt for quality of life as opposed to overall survival. 
No contradiction here. Physicians are obliged to present all options to the patients but they have to emphasize survival. The are very aware that very few patients with potentially deadly disease would not  be happy if they were steered towards the option with the lesser chance of survival. 

Doctors by training have to recommend the "standard of care" but  their insights in  end of life issues is such that they may chose to opt out.

 Abstract below

Arch Intern Med. 2011;171(7):630-634. doi:10.1001/archinternmed.2011.91
Background  Patients facing difficult decisions often ask physicians for recommendations. However, little is known regarding the ways that physicians' decisions are influenced by the act of making a recommendation.
Methods  We surveyed 2 representative samples of US primary care physicians—general internists and family medicine specialists listed in the American Medical Association Physician Masterfile—and presented each with 1 of 2 clinical scenarios. Both involved 2 treatment alternatives, 1 of which yielded a better chance of surviving a fatal illness but at the cost of potentially experiencing unpleasant adverse effects. We randomized physicians to indicate which treatment they would choose if they were the patient or they were recommending a treatment to a patient.
Results  Among those asked to consider our colon cancer scenario (n = 242), 37.8% chose the treatment with a higher death rate for themselves but only 24.5% recommended this treatment to a hypothetical patient ({chi}21 = 4.67, P = .03). Among those receiving our avian influenza scenario (n = 698), 62.9% chose the outcome with the higher death rate for themselves but only 48.5% recommended this for patients ({chi}21 = 14.56, P < .001).
Conclusions  The act of making a recommendation changes the ways that physicians think regarding medical choices. Better understanding of this thought process will help determine when or whether recommendations improve decision making.
 Comment Below From Huffpost
"I think the doctors, when they were imagining themselves as the patient, were saying, 'Yes, there is a higher survival, but I don't want to put up with these horrible side effects,'" Dr. Peter Ubel of Duke University told WebMD. "On the other hand, when they are making recommendations for the patients, it is easier to push those emotions aside.''
Here's how the study worked. In the first scenario, doctors were asked to imagine that their patients had been diagnosed with colon cancer and had two options: Surgery 1 would cure cancer in 80 percent of the patients with no complications; 16 percent would not be cured and would die within two years; and the remaining 4 percent would be cured, but would have serious side effects like wound infection or chronic diarrhea. Surgery 2 would cure 80 percent of patients with no complications, but 20 percent would not be cured and would die within two years.
The study's authors explained that the two scenarios were selected because they involve a "trade-off between the risk of death and the chance of four surgical complications."
The results?

Of the 242 physicians who returned the colon cancer questionnaire, only 24.5 percent of the physicians said they'd recommend surgery two -- aka the procedure with the higher mortality rate -- for their patients. But when asked what they'd do personally, 37.8 percent of the physicians said they would opt for surgery two.
A similar pattern held up in a second scenario.
This time, primary care physicians were asked to imagine that a patient had contracted a new strain of avian flu for which there was an immunoglobin treatment available. Patients who declined the treatment faced a 10 percent mortality rate and 30 percent hospitalization rate for an average of one week. If patients opted to take it, their hospitalization and mortality rates would be cut in half, but the treatment would kill 1 percent of patients and result in 4 percent being permanently paralyzed.
Of the 698 physicians who responded, 48.5 percent recommended that their patients avoid the immunoglobin treatment, but when asked what they would do themselves, that number jumped to 62.9 percent. They attribute this, in part, to the idea of "betrayal aversion," i.e., the fear that something meant to prevent harm actually causes potentially even more harm itself. They suggest that when physicians make recommendations for others, they tend to focus on the decision that's easiest to defend, which is typically the option with the lowest mortality rate, regardless of the potential side effects.
The study's authors go on to conclude that just because physicians often make different decisions for themselves, it does not mean their personal decisions are necessarily better, given that the best choice in each scenario is debatable

source : huffington post

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