nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Tuesday, April 12, 2011

STUDY: Doctors Choose Riskier Treatment For Themselves Than For Patients

Because I feel comfortable taking a chance for myself, but not for patients.  Is that surprising?

I saw an article by Assoc Press (Apr 11), that described a study of over 700 primary care doctors.  Given two scenarios in which an alternative treatment choice was available, and where the choice came down to a greater risk of death versus risk of long-lasting complications, doctors were more likely to go for the gold:  a higher risk of death in order to have lower risk of complications.  They recommended this option less often for their patients.

I don't find anything surprising here.  From day one, I was taught "do no harm."  In general, death was considered the greatest harm.

That's not always the case, of course, but it tends to be the standard against which alternatives get measured.  Yes, there is a "living death" that many would not prefer, and certainly some patients would also prefer to take their chances rather than suffer complications for a long time.

When there are treatment alternatives, there is an ethical imperative to present them both, giving your judgment as to the relative merits and dangers of each.  Almost every time this has happened to me, I have to give a summary and refer the patient to outside data (journals, etc) if they wish to check it out themselves (some people don't want to).

It's impossible to say everything.  And it's not possible to communicate eight years of training.  But you do your best.

The scenario in this study asks what physicians say if the patient, after all the explanation, says, "What would you do if it were you?"

The bottom line is, I will sometimes take more risks when I am risking myself.  I own this body, and can make those decisions.  I don't own the patient's...and will err (if there is any error) on the side of caution.

The scenarios used in the study were (1) a colon cancer treatment decision, and (2) treatment versus no treatment for influenza.  The choices were described in some detail.  The conditions were reasonable, and ones that could--and do--occur.  I recommend reading the details; you can find a fair description at Science Daily (Apr 11).

[The scenarios compared relatively small but real differences in risk. Most patients obtain a cure from colon cancer, and few patients die of the flu]

For Onion Peelers, the study is here  (Arch Int Med, 7 Apr):
"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 (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 (21 = 14.56, P < .001). "

Note that the cancer treatment scenario showed a trend, but didn't quite reach a p-value of 0.05.  With 700 study subjects, we should take this with a grain of salt.

I can only speculate that the differences between the results of flu versus cancer represents a psychological element:  i.e., a perceived difference in how serious the two diseases can be.

The lesson here is, if you ask your doctor how they would treat themselves, you should realize that this opens a door to a different set of values...theirs.

Doc D

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