Ubel PA. Arch Intern Med. 2011;171:630-634.
The act of making a recommendation influences how
physicians think about medical choices, according to a survey.
Peter A. Ubel, MD, of the Sanford School of
Public Policy and the Fuqua School of Business at Duke University, and
colleagues surveyed two random samples of US primary care physicians (general
internists and family medicine physicians) listed in the American Medical
Association Physician Masterfile. Covariates included age, sex, race and
ethnicity, type of medical degree, practice setting, patient volume, and how
they allocated their professional time (eg, seeing patients, teaching, etc.).
The first group (n=500) of PCPs were sent a colon cancer
scenario in which they were asked to imagine that they had been diagnosed with
the disease and could choose between two types of surgeries or that a patient
of theirs had been diagnosed and it was up to the physician to recommend one
surgery over another.
Surgery 1 was presented as having a complication-free
success rate in 80% of patients, but a postoperative mortality rate within 2
years for 16% of patients. The surgery was also presented with additional
complications, including 1% of patients needing a colostomy, experiencing a
wound infection, chronic diarrhea or, conversely, intermittent bowel
obstruction. Surgery 2 was presented as curing the cancer in 80% of patients
while failing in 20%, all of whom died of colon cancer within 2 years.
Of the 242 physicians who completed and returned the
survey, 37.8% chose the surgery with a higher death rate for themselves; 24.5%
recommended the same treatment to their hypothetical patients. Multivariate
logistic regression analysis confirmed that the physician’s perspective
significantly influenced treatment choice (OR=0.55; 95% CI, 0.31-0.99).
The second group (n=1,600) of PCPs were randomly
assigned to imagine that they had contracted a strain of avian influenza new to
the US or that a patient of theirs had been. Each scenario stated that people
who contracted the virus had a 10% death rate and a 30% hospitalization rate.
Both scenarios also included a hypothetical experimental
immunoglobulin treatment that had been shown in Asia and Europe to cut in half
the chance of adverse events from the virus, meaning that with the treatment,
there was a 5% death rate and a 15% hospitalization rate, with an average
1-week length of stay. However, the treatment was presented as having a 1%
death rate in patients and a 4% rate of neurological paralysis, especially in
the lower extremities.
Of the 698 physicians who completed and returned the
second survey, 62.9% of respondents chose not to use the experimental
treatment, whereas 48.5% chose it on behalf of patients. Multivariate logistic
regression analysis showed that the physician’s perspective greatly
influenced treatment choice (OR=0.55; 95% CI, 0.41-0.75), but choice did not
correspond with the physician’s age, sex or volume of patient care.
“The very act of making a recommendation changes
the way physicians weigh medical alternatives,” the researchers concluded.
“Better understanding of this thought process will help determine when or
whether recommendations improve decision-making.”
“Physicians may be more able to imagine their
patients’ abilities to adapt to significant disability than the patients
themselves could,” wrote Eric Shaban, MD, and colleagues of the
Palliative Care Program, department of medicine, University of Rochester
Medical Center. “But only when considering the consequences for themselves
can they imagine the level of suffering that might be a by-product of an
Disclosure: The researchers of the study and the accompanying
editorial report no relevant financial disclosures.