I've always found it suspect when I learn that someone employs one set of criteria when making decisions for themselves but quite another when advising me. Turns out that for many physicians, that is exactly the case, as reported in this issue of Archives of Internal Medicine. Good thing, I guess, that I'm long on questioning advice received from many physicians, as is always evident in our podcast.
The study surveyed physicians in primary care practices in the United States and posed one of two scenarios: one involved colon cancer treatment and the other treatment for avian flu. Each scenario had two possible management strategies, with one offering a better chance of survival but with the potential cost of some serious or unpleasant side effects, while the other offered slightly poorer survival chances but a reduced risk of negative side effects. Physicians generally were more likely to undergo the riskier treatment themselves but recommend the less risky treatment to their patients. Why? I offer the interpretation that there's a lot of paternalism in medicine, while Rick takes a more comprehensive view.
Rick opines that first of all, this is such a likely question from patients. "What would you do if you were in my circumstances," may be one of the most common queries heard daily by physicians in clinical practice. Both Rick and the authors of the study suggest that physicians are operating here with a number of biases, one of which is known as betrayal aversion. That's where harm caused by something designed to prevent harm is viewed as somehow worse than the same harm NOT involving betrayal. Docs are reluctant to recommend something that is supposed to help but also may harm.
Additionally, there are sins of omission and sins of commission. If harm results from not doing anything, we can write it off as the will of God or nature taking its course. But if harm results from use of a treatment that is worse than the same outcome happening 'naturally.'
Finally, previous research cited by the authors indicates that when people are involved in decisions for themselves they take a broad approach to information, pulling in multiple factors to reach a conclusion. Conversely, when involved in decision making for someone else, they tend to focus on a single aspect of the choices available. In this case that could mean the adverse events.
Well, so what? What I think this means is that in the current climate of informing patients and engaging them in the decision making process regarding their own healthcare choices, both parties need to be aware of such undercover biases when it comes to treatment options. I think of one benefit of AIDS activism: patients lobbied hard for being allowed to attempt sometime life-threatening treatments and use medications that may not have run the gamut of long term studies to assure both safety and efficacy. After all, they were going to die anyway. As a result of their courage the rest of us have reaped a potential benefit: becoming more informed and included in our own health management. This study helps extend that by illustrating bias in recommendations as yet one more factor to be aware of when selecting among treatment options.
Other topics this week include viral shedding among people with herpes infections in JAMA, good news regarding treating acne with antibiotics in Archives of Dermatology (online), and managing a sadly common complication of longstanding diabetes called diabetic neuropathy in Neurology (online). Until next week, y'all live well.