Physicians don't always choose same treatment they'd recommend for patients

Primary care physicians recommend treatment with the lowest risk of mortality for patients more often than they choose it for themselves, a study shows. But such decisions leave patients with a greater risk of treatment-related side effects.

The study's authors encourage primary care doctors to talk to patients about their treatment preferences and personal values before making a recommendation. Physicians also should explain to patients how they came to their decisions, said Peter A. Ubel, MD, lead author of the study and professor of public policy at Sanford School of Public Policy at Duke University in North Carolina.

"When making recommendations to patients, physicians can push aside any emotions that would lead them astray" and make a decision based on the evidence, said Dr. Ubel, faculty associate at Duke's Trent Center for Bioethics, Humanities & History of Medicine.

But, he added, that does not necessarily mean that physician recommendations are always objective and the best medical decisions. In fact, Dr. Ubel said, a doctor's guidance can be biased by factors besides emotions, such as a physician's specialty. He said a surgeon might be more inclined to recommend surgery to a patient, even if there are better options.

Researchers surveyed two groups of primary care physicians for the study in the April 11 issue of Archives of Internal Medicine. They presented each group with one of two hypothetical clinical scenarios. Physicians were selected randomly to imagine that the situation involved either a patient or themselves.

The first scenario was about a colon cancer diagnosis with two choices of surgery to treat the disease. Both procedures cured the cancer without complications 80% of the time. In one treatment, however, 20% of those who received the surgery died within two years. The other option had fewer deaths (16%), but there were risks for surgery-related complications, including chronic diarrhea.

Two hundred and forty-two physicians completed the survey. When asked to imagine that they had colon cancer, 38% chose the surgery with a higher death risk but fewer side effects. When making a recommendation for a patient, 25% selected that treatment.

Making sound medical decisions

The second scenario involved avian influenza infection. Without the hypothetical immunoglobulin treatment, 30% of infected people were hospitalized, and one in 10 died. Those who received the medication had lower hospitalization rates and death rates, but there was a 1% risk of death and a 4% risk of permanent neurological paralysis due to the drug.

Of the 698 physicians asked about this scenario, 63% chose to forgo treatment when imagining that they were infected. When making a recommendation for a patient, 49% selected this option.

"What happened in the study is [the physicians] weighed the pros and cons differently for themselves than they did for the patient," Dr. Ubel said. "There are times when I expect [doctors'] recommendations to be more dispassionate and objective and therefore better. But that doesn't mean they're always going to be better."

The key to physicians making sound medical recommendations is integrating the patient's concerns and values into the decision, said Timothy E. Quill, MD, author of an accompanying editorial in Archives. He is director of the Center for Ethics, Humanities and Palliative Care at the University of Rochester Medical Center in New York.

"If gaps exist between what [a doctor] would do [if he were] in the patient's position and what [he] is recommending for a patient, it is important for the physician to reflect on this disparity and evaluate himself for cognitive bias," Dr. Quill said.