Thursday, July 7, 2011

Did you know that doctors make different treatment choices for themselves than they recommend to their patients? A recent study found that doctors are more likely to take on the risk of death to avoid serious complications than they recommend to patients. (1) 

Here’s an example question from the study: To treat or not to treat Avian flu? Two-thirds of doctors said they would rather take a 10 percent chance of dying of Avian Flu than a 6 percent chance of death and 4 percent chance of paralysis from the treatment. Yet, more than half would recommend the treatment for their patients. Knowing what they know, understanding what they might face, considering whether or not they might get sued, doctors make different choices for patients than for themselves.

Surprising? Not really. 

First, we all make different decisions when other people face the consequences than we do when we bear consequences personally. Second, whenever we presume we know what other people want, there is a significant chance of being wrong. 

Interestingly, the study’s authors comment that–in their opinion–the doctors made better choices for their patients than for themselves, which implies that there was a “correct” choice to be made. I disagree. The correct choice is the one made by the fully informed patient, who, given all of his options, must bear the consequences of the decision. Period. As much as anyone may try, no one can truly stand in another’s shoes or pretend to know you as well as you do. 

Often there is no “right” answer.

Another concern about making decisions for others is the lack of any one appropriate course of action. In almost every situation there are choices, if not about the treatment, then about timing; if not about the action, then about the method; if not about the specific procedure, then about the doctor or facility one chooses. 

Every medical option has inherent trade-offs of benefits and risks. For example, many types of heart disease can be treated with lifestyle and medication instead of artery-opening surgery—if the patient is willing to change his habits and achieve symptom relief more gradually. Some slow-growing cancers can be watched instead of removed—if the patient is comfortable with the uncertainty of waiting. Even for minor issues patients make trade-offs: whether to endure allergy symptoms or handle side effects of allergy medication; whether to take strong pain relievers after minor surgery or avoid possible nausea. And there are significant choices at the end of life: to continue curative efforts or make one’s remaining days comfortable. 

Rarely can we classify a choice as “wrong,” but consumers definitely have personal circumstances and preferences. We weigh our alternatives and make decisions based on quality, price, and convenience.

 A common concern: Can patients be “informed” enough?

In most discussions about patient choice with policymakers and medical professionals, I hear concerns about complexity. They ask: Is health care simply too complicated for the average person to make a good choice? Haven’t studies shown that too many choices make decisions overwhelming for typical consumers? Isn’t it up to the experts to limit options or make prudent decisions on patients’ behalf? 

A colleague of mine likes to say that aviation is complex too, but a passenger doesn’t need to know how to fly a 747 before he goes on a trip; the pilot does. The passenger needs to decide where to go, how much he’s willing to pay, when to leave, acceptable layovers, and what he wants to do when he arrives. People use air travel for all sorts of different reasons, and make all sorts of different choices—while knowing almost nothing about airplanes or the laws of physics that keep them aloft.

Letting a doctor choose your procedure is a little like letting the pilot choose your destination—she will use her skills to get you somewhere safely, but may or may not take you to the destination you hoped for at the price and time you would have chosen.

A doctor interviewed in a recent news story said it this way: There are two experts in the room. The doctor is the expert about medical options, the patient is the expert on himself. You need both experts together to make the best choice. (2) 

What is certain is that when individuals are given an opportunity to participate in weighing their health care options, they make different choices (and very often choose less-invasive options) than when decisions are made for them. To be clear, the choices they make are not “worse” clinically, and may actually have positive effects beyond receiving care that is inherently more appropriate. 

Being an involved decisionmaker actually improves health outcomes. 

An interesting side effect of making one’s own choice is that the treatment we pick actually seems to go better. In one study, patients were either assigned to be in charge of their treatment decision or allowed physicians to make the decision on their behalf. Regardless of the treatment choice, patients who made their own decisions reported better physical and psychological outcomes. (3) 

In another study, patients were asked how much they participated in health care decisionmaking (after the fact). Those with minimal participation had significantly higher costs in the first year following treatment and reported lower overall quality of life and health in the first year. (4) 

These results are not exceptions. Across 17 clinical trials, individuals randomized to get the intervention they preferred (to begin with before the trial) had better outcomes than those who were indifferent to which intervention they might receive. (5) In other words, active participation in itself seems to produce a positive effect that doesn’t occur with passive acceptance. 

Choice-making as an essential element in treatment.

When it comes to decisions involving personal health and health care, the right decision is the one patients participate in making. We each own our health, and must live with the consequences of our choices. No one, not even a highly-trained physician, can decide what is best for us without our input. Every person weighs risk differently, even doctors themselves, who make different personal choices than they would recommend for their patients. 

Like travel, we each have different priorities in health outcomes. Choose where you want to go, then find a safe and experienced pilot who can help get you there.

References 

1.    Ubel, P. A., Angott, A. M., & Zikmund-Fisher, B. J. (2011). Physicians recommend different treatments for patients than they would choose for themselves. Archives of Internal Medicine, 171, 630–634.

2.    Schwitzer, G. (2011, June 20). Telling the story of variations in health care and shared decisionmaking in a TV news story. Medpage Today. Retrieved from http://www.medpagetoday.com/Blogs/27117?utm_content=&utm_medium=email&ut...

3.    Kennedy, A. D. , Sculpher, M. J., Coulter, A., Dwyer, N., Rees, M., Abrams, K. R., … Stirrat, G. (2002). Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: A randomized controlled trial. JAMA, 288(21), 2701–2708. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=195580

4.    Clark, N. M., Janz, N. K., Dodge, J. A., Mosca, L., Lin, X., Long, Q., … Liang, J. (2008). The effect of patient choice of intervention on health outcomes. Contemporary Clinical Trials, 29, 679–686.

5.    Preference Collaborative Review Group. (2008). Patients’ preferences within randomised trials: Systematic review and patient level meta-analysis. BMJ, 337, a1864. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659956/?tool=pubmed


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