PODCAST
Dr. Maggie Lowenstein
Source: Lowenstein, M. Choosing our words wisely. JAMA Internal Medicine. 2-16;176(9):1249-1250. Used with permission and recorded by Dr. Lowenstein.
As Dr. Lowenstein illustrates, discussing the risks and downstream potential harms (physically and financially) of overuse with patients is fraught with pitfalls. There are so many ways the conversation can go awry. For instance, people who are unsettled by their symptoms may place a low priority on concerns about potential misuse of resources. Indeed, asking them to consider costs might seem callous and inhumane. The general perception is, “better safe than sorry,” and it can be difficult to help patients appreciate the limitations and downsides of tests or treatments. The discussion can be even more difficult when a patient under-utilizes medical care because of fear or distrust. In either case, value conversations are difficult and benefit from planning, training, and practice.
Dr. Lowenstein, once again, highlights one of the root causes of this problem:
PODCAST
Dr. Maggie Lowenstein
Source: Lowenstein, M. Choosing our words wisely. JAMA Internal Medicine. 2-16;176(9):1249-1250. Used with permission and recorded by Dr. Lowenstein.
These conversations can feel taxing for clinicians. Consider explaining to patients with acute respiratory infections that they do not need antibiotics. There are many reasons clinicians may want to prescribe unnecessary antibiotics in this setting, including “perceived or explicit patient demand, a desire to do something meaningful for patients, a desire to conclude visits quickly, or an unrealistic fear of complications.”2 Plus, patients and clinicians both routinely overestimate the benefits of testing and treatments, while not realizing the many potential downstream harms, so there is an inherent bias toward more testing and treatment.3
In a systematic review of 48 studies involving over 13,000 clinicians, clinicians routinely overestimated benefits and underestimated harms, especially for medications (Figure 1).
A study of primary care physicians found that as the day wore on, the likelihood of prescribing antibiotics for acute respiratory infections increased, suggesting decision fatigue could “progressively impair clinicians’ ability to resist ordering inappropriate treatments.” 2
Source: Linder JA, Doctor JN, Friedberg MW, et al. Time of Day and the Decision to Prescribe Antibiotics. JAMA internal medicine. 2014;174(12):2029-2031. doi:10.1001/jamainternmed.2014.5225.
Figure Legend: Antibiotic Prescribing by Hour of the Day
Diagnoses for which antibiotics are sometimes indicated were otitis media, sinusitis, pneumonia, and streptococcal pharyngitis. Diagnoses for which antibiotics are never indicated were acute bronchitis, nonspecific upper respiratory infection, influenza, and nonstreptococcal pharyngitis. Linear trend in session hours (combining 8 AM with 1 PM, 9 AM with 2 PM, 10 AM with 3 PM, and 11 AM with 4 PM): P < .001 for antibiotics sometimes indicated; P < .001 for all acute respiratory infection visits; and P < .002 for antibiotics never indicated. During clinic sessions, the proportion of acute respiratory infection visits for which antibiotics were sometimes indicated did not vary significantly from hour to hour (P = .64).
The perception of many health care professionals is that patient demands frequently drive overtesting, but studies suggest the “demanding patient” is actually much less common than most physicians think.6 In a study at 3 cancer centers in Philadelphia, only 8% of patient-physician encounters involved a patient “demand.”7 When considering these “demands,” physicians viewed the majority of them as “clinically appropriate.” As Dr. Anthony Back said in the accompanying editorial to this study in JAMA Oncology: “Suddenly, the demanding cancer patient looks less like a budget buster and more like an urban myth.”7
In a study done in 10 academic emergency departments, physicians often prescribed antibiotics because they perceived that patients wanted them, but their perception was correct only a quarter of the time.7 In the vast majority of cases, patients did not actually desire antibiotics and that impression was simply a projection from the treating physician (“They came to the emergency department with bronchitis, of course they are expecting antibiotics, why else would they come here?”).
Furthermore, physicians worry if they do not prescribe what they believe the patient wants, then it could adversely affect their patient satisfaction scores. But patient satisfaction correlates with effective communication strategies and perceived clinician empathy rather than specific interventions.8,9
A systematic review found that patients with back pain expected acknowledgment of their pain, a physical examination, a clear explanation of the cause of the pain, and a clear treatment plan. Expectations about imaging or specialist referral were less common and had less effect on satisfaction.10,11
ARTICLE
Read more about decision fatigue and how it affects all clinicians and their likelihood of writing unnecessary prescriptions.
ARTICLE
This article thoroughly debunks the myth that patients and their demands are a leading factor in high medical costs. Read to learn more about this study and the necessary shifts in the clinician-patient relationship.
BOOK
This book dissects the differences in understanding between what patients and doctors believe they are communicating to one another and what they actually believe they understand.
Click to visit study and view expanded figure.