The act of making a recommendation appears to change the way physicians think regarding medical choices, and they often make different choices for themselves than what they recommend to patients, according to a survey study published in the April 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
"Patients facing difficult decisions often ask physicians for recommendations," the authors write as background information in the study. "However, little is known regarding the ways that physicians' decisions are influenced by the act of making a recommendation."
Peter A. Ubel, M.D., of Duke University, Durham, N.C., and colleagues tested whether making a treatment recommendation changes the way physicians think about medical decisions. The authors surveyed two samples of U.S. primary care physicians, and presented each with one of two clinical scenarios.
In the first scenario, 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 percent of patients, however one surgery had a higher mortality (death) rate, but fewer adverse effects, whereas the second surgery had a lower death rate but a small percentage of patients experienced colostomy, chronic diarrhea, intermittent bowel obstruction or a wound infection.
A total of 242 physicians returned the colon cancer questionnaire (response rate of 48.4 percent), and when asked to imagine they had received the cancer diagnosis, 37.8 percent of physicians chose the surgical procedure with a higher rate of death, but a lower rate of adverse effects. Conversely, when asked to make a recommendation for a patient, only 24.5 percent of physicians chose this option.
The second scenario asked 1,600 physicians to imagine that a new strain of avian influenza had just arrived in the U.S. One group of physicians were asked to imagine they had been infected, and the other group was asked to imagine that his or her patient was infected. One treatment was available for this strain of influenza: an immunoglobulin treatment, without which persons who contract flu have a 10 percent death rate and a 30 percent hospitalization rate with an average stay of one week. The treatment would reduce the rate of adverse events by half, however it also causes death in 1 percent of patients and permanent neurological paralysis in 4 percent of patients.
The avian influenza scenario was returned by 698 patients (response rate of 43.6 percent), and 62.9 percent of physicians 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 percent of physicians recommended not getting the treatment.
"In conclusion, when physicians make treatment recommendations, they think differently than when making decisions for themselves," the authors conclude. "In some circumstances, making recommendations could reduce the quality of medical decisions. In at least some circumstances, however, such as when emotions interfere with optimal decision making, this change in thinking could lead to more optimal decisions. In debating when it is appropriate for physicians to make treatment recommendations to their patients, we must now recognize that the very act of making a recommendation changes the way physicians weigh medical alternatives."
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