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September 16, 2020

BehindTheMedspeak: When doctors become patients

Doctor -- patient - relationship

From Dr. Eric D. Manheimer's New York Times Op-Ed page essay:

I wasn't a doctor anymore. I was a patient.

The Archives of Internal Medicine published a much-discussed study that showed that doctors might recommend different treatments for their patients than they would for themselves. They were far more likely to prescribe for patients a potentially life-saving treatment with severe side effects than they were to pick that treatment for themselves.

Understandably, people are worried that this means doctors know something they're not telling their patients. But my own experience with illness taught me a simpler truth: when it comes to their own health, doctors are as irrational as everyone else.  

Here is the abstract of the Archives of Internal Medicine paper alluded to above.

Physicians Recommend Different Treatments for Patients Than They Would Choose for Themselves

Background: Patients facing difficult decisions often ask physicians for recommendations. However, little is known regarding the ways that physicians' decisions are influenced by the act of making a recommendation.

Methods: We surveyed 2 representative samples of US primary care physicians — general internists and family medicine specialists listed in the American Medical Association Physician Masterfile — and presented each with 1 of 2 clinical scenarios. Both involved 2 treatment alternatives, 1 of which yielded a better chance of surviving a fatal illness but at the cost of potentially experiencing unpleasant adverse effects. We randomized physicians to indicate which treatment they would choose if they were the patient or they were recommending a treatment to a patient.

Results: Among those asked to consider our colon cancer scenario (n = 242), 37.8% chose the treatment with a higher death rate for themselves but only 24.5% recommended this treatment to a hypothetical patient ({chi}21 = 4.67, P = .03). Among those receiving our avian influenza scenario (n = 698), 62.9% chose the outcome with the higher death rate for themselves but only 48.5% recommended this for patients ({chi}21 = 14.56, P < .001).

Conclusions: The act of making a recommendation changes the ways that physicians think regarding medical choices. Better understanding of this thought process will help determine when or whether recommendations improve decision making.

How about an example from my own experience, when what I chose to do in terms of treatment for myself was completely the opposite of what I would have insisted on for a patient?

It happened around the year 1999 or 2000, when I was completely absorbed with inline skating (rollerblading, in the vernacular).

I fell on concrete or asphalt and landed on my right hand, among other body parts. 

After the initial shock and wave of pain, I picked myself off the ground and checked myself out to see if anything looked amiss or wasn't moving properly.

The only damage I could detect was to the distal interphalangeal joint (DIP; the one closest to the fingertip) of my right middle finger, which was very painful, tender, swollen, and didn't move much at all.

In addition, the joint was no longer aligned correctly — the fingertip veered off about 15° toward the little finger.

The skin wasn't broken, the damage was entirely internal.

I started skating again (it was a really, really nice day and I was in that kind of mood where you just want to keep doing what you're doing) and meanwhile played with the finger, trying to flex the tip, which wasn't possible because the joint kept swelling more and more.

After about an hour even I, an anesthesiologist, realized I'd broken the finger, probably across the joint space, which is much worse than through the shaft in terms of outcome because of the increased chance of arthritis.

I realized I had two choices: 1) do nothing, skate on, when I was done stop by CVS, buy a splint and splint the finger in the position of function (flexion), take some aspirin or Tylenol for the pain if necessary, and let the finger heal on its own, or 2) go to the E.R., wait forever to be seen, get examined, get x-rayed, be told my finger was broken, have my finger splinted, be advised to see an orthopedic surgeon, see the surgeon who'd say I had to have the fracture reduced and pinned under anesthesia because doing nothing would result in an arthritic, useless joint that would become  increasingly painful and deformed as time went on, have the surgery, have a cast put on the hand which would then cause the hand itself to lose strength as it atrophied, eventually have the cast removed, have another surgical procedure to have the pins removed, and rehabilitate the hand.

And of course that's not counting the possiblity of a wound infection, osteomyelitis, or other complications of surgery.

As I saw it, option 2 meant ruining the perfectly fine day I was having, ruining a second day with a doctor's appointment, ruining a third day with the surgical procedure, ruining a fourth day with an appointment to see how the fracture was healing post-op, ruining a fifth day having the pins removed, and meanwhile being unable to use my right hand while it was in a cast and then being saddled with a weak hand for weeks until I got it back up to full strength, which meant more days lost to physical therapy.

I chose option 1, kept skating for a couple more hours, then got my splint and took some aspirin when I got home.

Within a week it stopped hurting.

The swelling went down over a week or two but it stayed bent.

In addition, the joint is larger than the corresponding one on the other middle finger.

It doesn't hurt at all, even on rainy days.

The range of motion isn't normal: whereas I can bend the left index finger DIP 90°, the right is capable of 45°.

Today, 12 or 13 years later, I'm certain the finger was broken, across the joint space.

So you see, I did just the opposite of what I would've told you to do if you'd come to my office with that injury.

And you know what?

I'd do the very same thing today if it happened again.

So yes, the title of that article — "Physicians Recommend Different Treatments for Patients Than They Would Choose for Themselves" — is indeed spot-on.

September 16, 2020 at 04:01 PM | Permalink


Comments

I tend to think a lot of the difference comes from having to practice "defensive" medicine. Too many hungry lawyers looking for a new case......So Dr. Smith do your peers recommend the same treatment for their patients with the same condition? Anything other than a "yes" leaves the doctor open to malpractice. Resulting in the "do as I say, not as I do" treatment. Even if it cost more money, time and discomfort/pain.

Posted by: Mike | Sep 17, 2020 10:07:13 AM

I don't find the results surprising either, being a doctor-patient myself. When choosing for patients, we tend to use 'hard' end points, like death or DALYs. When we make decisions for ourselves, we are at liberty to consider more nebulous criteria like comfort, familiarity, staff, location of treatment etc. I also believe that we as doctors are also more familiar with death and with that, at some level, we appreciate that 'living for the sake of living' can be a terrible existence.

Posted by: lewildbeast | Sep 16, 2020 9:10:34 PM

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