Double Standard for Doctors?

Doctors' Recommendations for Patients Often Different Than for Themselves, Study Finds

From the WebMD Archives

April 11, 2011 -- When facing a difficult medical decision, patients often ask their doctors what to do.

What the doctor recommends for a patient is likely to be different from what a doctor would decide for himself or herself, according to a new study. It sheds light on what may seem like doctors' double standards.

"The way the doctor weighs the risk and benefits of your alternatives could change dramatically depending on whether the doctor is thinking about what he or she would do or thinking about what you ought to do," says Peter A. Ubel, MD, a professor of business, public policy and medicine at Duke University, Durham.

''The bottom line of the study is, those tradeoffs feel different if you are the decision maker vs. the advice giver," Ubel tells WebMD.

The study is published in the Archives of Internal Medicine.

Doctors' Recommendations: Study Details

Little is known about what influences doctors' treatment recommendations, Ubel says.

To find out more, he and his colleagues surveyed two different groups of U.S. primary care doctors.They presented each with one of two scenarios.

The first scenario asked the doctors to imagine if they or one of their patients had gotten a diagnosis of colon cancer. They had two surgical options to treat it. Both procedures cured the colon cancer 80% of the time.

However, one had a higher death rate, 20%, and fewer adverse side effects. The other option had a lower death rate, 16%, but had side effects. The side effects included chronic diarrhea and having to have a colostomy. In this procedure, the end of the colon (large intestine) is brought through an opening in the abdominal wall, where the stool exits.

In all, 242 doctors returned the questionnaire. When they had the cancer diagnosis, nearly 38% chose the option with a higher death rate but fewer side effects. When they were making the recommendation for a patient, only 24.5% chose the same option.

In the second survey, doctors imagined a new strain of bird flu had arrived in the U.S. One group was told to imagine they were infected. Another group imagined a patient was.

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They had to decide on one treatment, immunoglobulin. Without it, 10% of patients die and 30% are hospitalized for about a week. The treatment was known to reduce the rate of side effects by half. However, the treatment led to 5% of patients dying from the flu, 1% dying from the treatment, and 4% contracting permanent paralysis.

Of the 698 doctors who responded, nearly 63% said they would not get the treatment themselves, to avoid the adverse effects. But only 48.5% would tell their patients not to get it.

Doctors' Double Standards: Implications

How to explain what seems to be the double standard?

"I think the doctors, when they were imagining themselves as the patient, were saying, 'Yes, there is a higher survival, but I don't want to put up with these horrible side effects,'" Ubel says. "On the other hand, when they are making recommendations for the patients, it is easier to push those emotions aside.''

"The simple message is this," Ubel says. "When you ask your doctor for advice, recognize your doctor 's advice will depend on how he or she is weighing the pros and cons of really complicated things. Their recommendation is not going to be just the result of medical facts ruling the day."

Ubel gives this example. A doctor tells a patient he would like to add chemotherapy to a regimen that has already included radiation and surgery. ''That sounds like a medical recommendation," Ubel tells WebMD.

"But there is a huge value judgment underlying that. They think the side effects of chemo are worth the increased chance of survival. But what if there is a 1% reduction in the 15-year recurrence rate and it means six months of vomiting, hair loss, and misery?"

For that reason, he says, ''asking a doctor for advice would only be part of a conversation in which you determine the right or wrong decision. Make sure you have a nice conversation about the pros and cons of the alternatives and how you feel about those pros and cons. If your doctor understands your values better, you are likely to get a better recommendation."

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Doctors' Double Standards: Perspective

The study findings suggest that doctors may weigh decisions more towards survival when recommending treatments for others, says Timothy Quill, MD, director of the Center for Ethics, Humanities and Palliative Care at the University of Rochester Medical Center, New York.

He wrote a commentary to accompany the study.

However, he says, it's important when making medical decisions to weigh both length of life and quality of life.

"When making decisions for themselves, the doctors [surveyed] were willing to take some survival risks to maximize qualify of life concerns," Quill tells WebMD.

He, too, advises doctors to find out the values and concerns of patients before recommending a treatment.

Asking your doctor that age-old question "What would you suggest if it were your mother or brother?" might be helpful, too, he says. "It forces them to think about the quality-of-life concerns."

WebMD Health News Reviewed by Laura J. Martin, MD on April 11, 2011

Sources

SOURCES:

Peter A. Ubel, MD, professor of business, public policy and medicine, Duke University, Durham, N.C.

Timothy Quill, MD, director of the Center for Ethics, Humanities, and Palliative Care, University of Rochester Medical Center, Rochester, N.Y.

Ubel, P. Archives of Internal Medicine, April 11, 2011; vol 171: pp 630-634.

Shaban, E. Archives of Internal Medicine, April 11, 2011; vol 171: pp 634-635.

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