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Doctors, Patients Take Different View on Tough Medical Choices

But both perspectives are necessary and valuable, study shows

FRIDAY, June 2, 2006 (HealthDay News) -- Whether it's cancer, HIV, or even a hypothetical bird flu pandemic, health crises can force people to make tough medical decisions, quickly.

Now, new research suggests a patient makes these decisions in a way that's very different from that of their family members or doctors.

"When you're a patient, and you're sick, and you're just trying to absorb all the information and the emotions of a new diagnosis, it's very difficult to grasp the whole story," said study author Brian J. Zikmund-Fisher, research investigator at the University of Michigan Medical School, in Ann Arbor. In that case, he said, "you grab onto one part of the story and lose sight of the whole picture."

So, helping patients imagine what their doctor might think of a particular treatment choice, "might be a very good way to help patients get a bigger perspective on decisions they might face," said Zikmund-Fisher, who is also affiliated with the VA-Ann Arbor HSR & D Center of Excellence.

In their study, published in the June 2006 Journal of General Internal Medicine, his team conducted an Internet survey with nearly 2,400 men and women over the age of 21.

Participants were randomly assigned to one of four groups, each of which was asked to imagine facing two medical decisions as if he or she were a different "player" in the health-care setting: either the patient, the patient's doctor, a parent making a choice on behalf of their underage boy or girl, or the medical director of the hospital offering treatment.

All the respondents faced two scenarios, each requiring serious medical decisions.

The first involved deciding whether or not to get a new vaccine against a deadly flu. Participants were told that without the vaccine, there was a 10 percent chance of dying from the flu. However, the vaccine itself -- which was based on a weakened version of the flu -- also presented a risk of death estimated at 5 percent.

In the second scenario, a similar risk calculus was presented with respect to a slow-growing cancer. The risk of death attached to doing nothing about the cancer had to be weighed against the risk of death linked to chemotherapy.

Zikmund-Fisher and his colleagues found that the choices made when faced with both "stories" varied significantly depending on which "character" was making the decision.

"Patients" were less likely to choose to vaccination or chemotherapy than all other scenario participants.

In the "deadly flu pandemic" scenario, just 48 percent of people who imagined themselves as the patient said they'd try the vaccine, compared to 57 percent of those deciding for their child, 63 percent who put themselves in the role of vaccinating physician, and 73 percent of people told to act as the medical director of a hospital.

In the "chemotherapy" scenario, the numbers were similar: 60 percent said they would use it if they were the patient, 72 percent chose it for their child, 68 percent said they would advise the treatment to patients as a doctor, and 68 percent said they would support use of chemotherapy in this situation if they ran a busy hospital.

Advanced age did appear to play a role in making decisions, the researchers found. Those 65 and older were much less likely to choose to treat their cancer with chemotherapy than those under 65. By contrast, the elderly were much more likely to get vaccinated against the flu than their younger counterparts.

When asked to describe their emotional state of mind when confronted with these decisions, the authors found that those playing the parental role were the most likely to experience feelings of anxiety, distress, conflict, concern, worry, and responsibility.

"Physicians" were the next highest "emotionally activated" group, followed by "medical directors", and, lastly, "patients."

The researchers concluded that medical professionals were much more likely than patients to go with proactive "survival" choices that involved having treatment.

Why might this be so? According to the Michigan team, patients appear to juggle many factors when making a decision. Some may be fearful of accepting responsibility for an aggressive treatment choice that might cause more harm than good.

On the other hand, medical professionals appear to be more focused on taking advantage of treatment options -- perhaps in order to be able to say they did everything they could to help the patient.

Zikmund-Fisher and his team suggest, therefore, that caregivers and family members play a key role in advising patients -- helping them view their choices through a wider lens.

"By taking a step back and putting yourself into someone else's shoes, it can perhaps help," said Zikmund-Fisher. "It might not always change your decision, but it might help you better understand your situation and make a decision that's more in tune with your overall preferences."

Dr. Ezekiel Emanuel, chairman of the department of bioethics at the Clinical Center at the National Institutes of Health in Bethesda, Md., viewed the findings as a wake-up call for doctors. He believes many doctors have perhaps pulled back in recent years from fully participating in the health-care decisions their patients make.

"It's a warning to doctors that you can't just lay out cafeteria-style options and leave it to the patients," he said. "You have to be more engaged."

"Doctors should absolutely be involved," added Emanuel. "It's critical. And more importantly, doctors shouldn't be hesitant about making recommendations. There has been a tendency for doctors to be a little bit resistant about putting forward their opinions because of the increase in patient autonomy over the last 20 years. And I think that's clearly a mistake."

More information

For more on medical decision-making, visit the Foundation for Informed Medical Decision Making.

SOURCES: Brian J. Zigmund-Fisher, Ph.D., research investigator, University of Michigan Medical School, and VA-Ann Arbor HSR & D Center of Excellence, Ann Arbor, Mich.; Ezekiel Emanuel, M.D., Ph.D., chairman, department of bioethics, The Clinical Center, National Institutes of Health, Bethesda, Md.; June 2006 Journal of General Internal Medicine
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