Practicing in an Age of Uncertainty

Kim BellardIf you've ever had a hard time trying to decide what's best for your health (e.g., Sorry, There's Nothing Magical About Breakfast), perhaps you can take comfort in the fact that physicians often aren't so sure either.

Or perhaps not.

A new study in Annals of Surgery, and nicely reported on by Julia Belluz in Vox, focused on surgical uncertainty.  The researchers sent four detailed clinical vignettes to a national sample of surgeons, seeking to get their assessment on the risks/benefits of operative and non-operative treatment, as well as their recommendations. You'd like to think there was good consensus on what to do, but that was not the case.

In one of the vignettes, involving a 68 year-old patient with a small bowel blockage, there was fairly universal agreement -- 85% -- that surgery was the best option.  In the other three vignettes, though, the surgeons were fairly evenly split about whether to operate or not, even on something as common as appendicitis.

So, there may be a "right" answer but you might as well flip a coin in terms of getting it, or there may just not be a right answer.  Both options are troubling.

The authors believe that surgeons are less likely to want to operate as their perception of surgical risk increased and the benefits of non-operative treatment increased, and more likely to want to operate as their perception of surgical benefit increased and non-operative risk increased.  The problem is that surgeons vary dramatically -- literally from 0 to 100% -- on their perceptions of those risks.

Vox quoted Ashish Jha, a physician and professor of health policy at Harvard, as saying: "The truth is that most of the surgeons in their sample are quite experienced, and yet have wildly different assessments of risks and benefits among similar patients."  Dr. Jha called the findings "deeply disturbing," noting that most of us are bad at evaluating risk -- and surgeons are no exception.

Most surgeons based their estimates of risks/benefits on their experience, their training, and -- if you're lucky -- on whatever literature might be available, but it is doubtful that we can usually expect an objective, quantifiable assessment.

The American College of Surgeons has developed a "surgical risk calculator" to help surgeons better gauge these risks, using data from a large dataset of patients.  However, an earlier related study from the same team of researchers found that it doesn't make much difference.  The calculator did narrow the variability of surgeons' assessment of risk, but: "Interestingly, it did not alter their reported likelihood of recommending an operation."

Oh, well.

The lead author told Medscape that 45% of the physicians surveyed had not been previously aware of the calculator's existence, even though it has been available for several years.  And only 6% of those who had been aware of it reported using it routinely.  All in all, it would appear that risk assessment may not be the core of the problem.

It is not just surgeons who aren't always sure of the right course of action, of course.  A study in the American Journal of Managed Care found that 62% of physicians reported that they found the "uncertainty involved in providing patient care disconcerting."  The discomfort with uncertainty did not vary appreciably between type of specialty.

The study looked at how the Choosing Wisely initiative has helped physicians reduce use of unnecessary tests and procedures, and the answer appears to be, not very much.  Ninety-six percent of physicians who were aware of Choosing Wisely did agree that it was a legitimate source of guidance, but almost 60% of physicians weren't aware of it.  Moreover, even among physicians aware of Choosing Wisely, almost 30% (46% of surgeons) felt it hadn't "empowered" them to reduce such tests and procedures.

Physicians want to do the right things.  Ninety-seven percent agreed that doctors should limit unnecessary services, 98% believed they should be aware of/adhere to clinical guidelines, and 92% felt physicians have responsibility to control costs,  Only 31% felt there was too much emphasis on costs, and only 28% agreed that doctors were "too busy" to worry about cost.

On the other hand, only 37% felt they understood the costs of the tests and services they order, and only 21% thought "physicians across specialty are likeminded in their commitment to reducing unnecessary treatments."  Physicians reported also pressure from patients, both for ordering more tests and procedures (68%) and for referrals to consultants (52%).  Almost half (46%) admitted ordering tests/procedures out of malpractice concerns.   The problem isn't just with physicians.

Then there is the example of PSA tests.  In 2008 the US Preventive Services Task Force recommended routine PSA tests not be given to men over 75, and in 2012 broadened that recommendation to all ages.  Yet data suggest that the group least likely to need the tests -- men over 75 -- had the smallest declines in rates of testing.  Almost 40% of this age group are still getting the test, which is not far from the previous rates.

As one researcher told The New York Times,   "That’s just insanity...bad medicine, poor use of health care resources and poor decision-making.”

There's all too much of that in our health care system.

We all share in the problem.  As Dr. Jha said, humans are usually not good about evaluating risk.  We're especially bad when there isn't good -- and understandable -- information to help inform our decisions.  Health care is just not an industry that uses data well, nor one that is very transparent about the data that does exist.

Look at the recent controversy over CMS wanting to move to a simpler, star rating for hospitals, which the industry managed to block.   As noted health policy guru Michael Millenson recently wrote, "Individual hospitals and the industry remain quick to point out flaws in others' report cards to the press and policymakers while keeping mum about the wealth of comparative quality information they use internally."        

It's not so clear to me that there is such a "wealth" of information already available, especially not at the individual hospital/physician/condition levels, but there should be, and it should be better used.  Until then, we'll have to keep living -- and dying -- with the uncertainty.
Practicing in an Age of Uncertainty was authored by Kim Bellard and first published in his blog, From a Different Perspective.... It is reprinted by Open Health News with permission from the author. The original post can be found here.