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 treatmen
I actually would have thought that the differences would have been stronger than they ended up being. My needle of trust in physician objectivity just went up! Though perhaps my expectation was a little too pessimistic.
Moreover, the discrepancy is exactly in the direction I would want to see in my doctor – while they may be willing to risk death themselves, they should quite rightly be less gung-ho when recommending treatments to their patients.
jld
@Peter Ellis
This is obviously a matter of personal preferences, I would choose the other way, death is a “one time” inconvenience, disabilities linger.
John Emerson
My father was a family practice / emergency room doctor who died of cancer. He had his doubts about oncologists, who he called “professional optimists”. Even so, when his first round of radition + chemo didn’t work, he ended up accepting a second round. They told him it would buy him 6 moths to 5 years, but he barely made the 6 months. When my mother got cancer she turned down the second round.
This kind of principal / agent problem is pretty widespread, not just in medicine. It’s different if it’s you, or when the principal is also the agent.
http://washparkprophet.blogspot.com ohwilleke
I find my physician clients to be more eager to have a forceful living will (i.e. pull the plug document) and to feel more strongly about it than the average estate planning client.
On the other hand, I frequently see physicians treating themselves make decisions for themselves that they would ordinarily consider unwise “from the outside” because they have more faith in their own abilities and fitness in general than they should, such as leaving a hospital too early.
John Emerson
There’s a saying “A doctor who treats himself has a fool for a patient”. I don’t think that it’s universally true. For example, a doctor who treats himself will avoid defensive medicine — unnecessary tests, or the kind of orthodox fail-safe medicine which might not be the best but can’t be publicly faulted. A doctor will also understand better what his own priorities are.
One the other hand, anxiety, pain, and medication can distort the judgement, and some doctors, as just was said, have enormous egos and tend to overestimate their strength and their powers
Roger Bigod
It’s no different from decisions in other fiduciary situations. Professionals should and generally do choose the low-risk alternative. The analogy is a financial adviser who puts his clients in diversified index funds, while taking a shot at a leveraged commodity play in his personal account.
http://occludedsun.wordpress.com Caledonian
Now the real question: how many of the doctors surveyed would give their patients the facts concerning the options and let them choose for themselves?
Roger Bigod
Physicians are conservative in the sense of being acutely aware of irreversible events, including loss of an inportant function like vision. This has a rational basis, of course, but it becomes reflexive. I once had an opthalmologist give me a jump start for a dead battery. First, the cables were laid out in a hyperneat fashion near the battery. The clamps were ckecked. Then polarity of the leads was checked against the battery three times. Contacts were checked for cleanliness. Finally, the cables were attached and I was given the go-ahead. Wonderful.
Physicians notoriously give inappropriate care to other physicians, because they try to treat them as “special”. One example is a distinguished Ob-Gyn doc at a private hospital with an excellent reputation. He developed rheumatoid arthritis and a perfunctory trial of some standard drugs wasn’t working, so the rheumatologist pulled out the stops and gave him colloidal gold, an old, dubious treatment that could produce dramatically good results. It was totally nonstandard to use it before a careful trial of standard drugs failed. The result was the rare but well known complication of cortical necrosis of the kidneys (=wipeout in laymen’s terms), requiring dialysis and a transplant. At the other end of the spectrum, a physician with classic complaint of a subarchnoid hemorrage (“worst headache I’ve ever had”) was pooh-poohed and allowed to go two weeks before he insisted on a spinal tap, which still showed faint traces of blood. The physicians, including a neurologists and a neurosurgeon, were in denial that a collegue could have a potentially fatal condition. The best advice for a physician with a potentially serious problem is to go to another town and check into a good hospital not using the MD title.
Or insist on standard care. A very distinguished Chairman of a department of Medicine had a condition that produced recurrent urinary tract infections. Not life-threatening but serious enough to need hospitalization and a course of antibiotics every 2-3 years. He would check in to his own medical service on a standard ward (not the VIP one for out-of-town consults) and insisted on standard care, including a history and physical by a medical student, the physical including a rectal exam because that was part of a complete physical. And if standard care wasn’t good enough for him, on principle it was a criticism of his medical service. The medical students were in terror of having him as a patient.
Selphin
I’d love to have access to that data set, I’m curious about the variation of these decisions as a functions of other variables (age, gender and so forth of the doctors).
John Emerson
The physicians, including a neurologists and a neurosurgeon, were in denial that a collegue could have a potentially fatal condition.
When my father was being diagnosed, the initial diagnosis was a rare sort of diabetes-like condition. (Can’t remember, and he’s not around to ask). He knew that the symptoms were consistent with pancreatic cancer, a more common disease for which he had the risk factors (alcohol , tobacco.) Pancreatic cancer is virtually incurable, and the other can be treated. My father basically diagnosed himself before his doctor did. Pancreatic cancer is no fun either for the patient or the doctor.
Brent Michael Krupp
I can’t quite remember the details (it’s been a while), but back in medical school and residency I recall encountering a few situations where VIPs got *worse* care because the treating physicians were either too careful or too aggressive (yes, those are opposites, it was more than one incident). My impression that you were better off being a nobody (at least at a teaching hospital).
Roger Bigod
John Emerson,
There’s a clinical adage that it’s best to consider treatable conditions before one that’s incurable, like pancreatic carcinoma. That approach also allows the patient and family time to deal with the possibility of an bad outcome. It sounds like the management of your father’s case was very sound.
John Emerson
It was sound in the sense of “orthodox”, but it also amounted to milking the cadaver-to-be, and his estate, and the government, and the insurance companies, to the max. It’s not like my dad didn’t understand these things.
John Emerson
Relating to the living will question, if I had an estate that amounted to anything I’d be pretty ferocious about trying to get it to my son instead to the medicine biz. An idea that popped into my head in the context of my father was conditional results-based medical contracts. Suppose the deal was “A year of life for $20,000, two years for $50,000, no cost for less than a year.” A lot of the overoptimistic but lucrative treatments would not happen, and that would be a good thing. Call it a death panel if you want. This could be done either privately, by the insurance compoany, or as part of socialized medicine.
Anthony
Here’s an interesting thought about that result that seemed to escape both the researchers and the popularizers:
“To my inexpert mind, the most obvious explanation is that doctors are probably less likely to sue each other (and are certainly less likely to sue themselves) than the average patient would be.”
Roger Bigod
John Emerson,
I’m sorry to hear about your father and your problems with the medical system. There are certainly situations where medical staff keep a moribund patient alive for weeks, and it’s hard not to conclude that fees for rendering “care” are the main motivation. But standard care for a patient who’s conscious and oriented has the effect of keeping them alive for 2-3 months with a dismal quality of life. It’s the kind of financial catastrophe that insurance and social insurance like Medicare should take care of.
Roger Bigod
The examples of substandard care of physician patients have the common factor of risk. The additional information I’d like to see would be personality profiles for risk taking and related issues like impulsiveness, feelings of personal imperviousness and boredom with routine. But I doubt that the results would be different from airline pilots who fly small aircraft with friends in bad weather or financial advisors who buy stocks for themselves they would never touch for a client.
Matt B.
That sounds a lot like the thing in Freakonomics about realtors holding out longer when selling their own houses than when selling a client’s.
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About Razib Khan
I have degrees in biology and biochemistry, a passion for genetics, history, and philosophy, and shrimp is my favorite food. In relation to nationality I'm a American Northwesterner, in politics I'm a reactionary, and as for religion I have none (I'm an atheist). If you want to know more, see the links at http://www.razib.com
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