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Funded by Department of Veterans Affairs

Funding Years: 2009-2012

Because CRC-predictive genetic tests offer the potential to optimize CRC screening efforts, improving the communication and use of such tests by the millions of veterans who are screened for CRC each year could result in both improved cancer surveillance and more efficient (and potentially reduced) VA resource utilization. Our study will provide empirical data about practical risk communication methods that can be used in the future by VA clinicians to present genetic tests to veterans and about patient-level barriers which will inhibit acceptance of genetic tests that predict colorectal cancer risk within the VA patient population. By evaluating alternate methods of communicating genetic test results before such tests actually become available, we hope to identify optimal approaches that can be integrated into VA genomics initiatives from the very start.

Angela Fagerlin (PI)

CBSSM investigators Holly Witteman, Andrea Fuhrel-Forbis, Angela Fagerlin, and Brian Zikmund-Fisher, along with CBSSM alumni Peter Ubel and Andrea Angott will give a plenary talk at the Society for Medical Decision Making's 32nd Annual Meeting in Toronto on Monday, October 25.  The talk is titled, "Colostomy is Better than Death, but a 4% Chance of Death Might Be Better Than a 4% Chance of Colostomy: Why People Make Choices Seemingly At Odds With Their Stated Preferences." 

Abstract:

Purpose: When asked for their preference between death and colostomy, most people say that they prefer colostomy. However, when given the choice of two hypothetical treatments that differ only in that one has four percent chance of colostomy while the other has four percent additional chance of death, approximately 25% of people who say that they prefer colostomy actually opt for the additional chance of death. This study examined whether probability-sensitive preference weighting may help to explain why people make these types of treatment choices that are inconsistent with their stated preferences.

Method: 1656 participants in a demographically diverse online survey were randomly assigned to indicate their preference by answering either, “If you had to choose, would you rather die, or would you rather have a colostomy?†or, “If you had to choose, would you rather have a 4% chance of dying, or would you rather have a 4% chance of having a colostomy?†They were then asked to imagine that they had been diagnosed with colon cancer and were faced with a choice between two treatments, one with an uncomplicated cure rate of 80% and a 20% death rate, and another with an uncomplicated cure rate of 80%, a 16% death rate, and a 4% rate of colostomy.

Result: Consistent with our prior research, most people whose preferences were elicited with the first question stated that they preferred colostomy (80% of participants) to death (20%), but many then made a choice inconsistent with that preference (59% chose the treatment with higher chance of colostomy; 41% chose the treatment with higher chance of death). Compared to the first group, participants whose preferences were elicited with the 4% question preferred death (31%) over colostomy (69%) more often (Chi-squared = 24.31, p<.001) and their treatment choices were more concordant with their stated preferences (64% chose the treatment with higher chance of colostomy; 36% chose the treatment with higher chance of death, Chi-squared for concordance = 36.92, p<.001).

Conclusion: Our experiment suggests that probability-sensitive preference weighting may help explain why people’s medical treatment choices are sometimes at odds with their stated preferences. These findings also suggest that preference elicitation methods may not necessarily assume independence of probability levels and preference weights.


It is with both sadness and joy that we announce that CBSSM Co-Director Dr. Angela Fagerlin will be assuming a new position as the inaugural Chair of

Population Health Sciences at the University of Utah. While we are very sad to see Angie leave, we congratulate her on this well-deserved opportunity and are thrilled to see her enter this new stage in her career.

Dr. Fagerlin has been with the University of Michigan for 15 years and Co-Director of CBSSM for the last 5 years. She has been an integral member of CBSSM and all its precursors—the Program for Improving Health Care Decisions and The Center for Behavioral and Decision Sciences in Medicine. Dr. Fagerlin will be greatly missed for her friendship, collegiality, mentorship, and the great science she has produced over the years.

As of January 2016, current Co-Director of CBSSM Dr. Raymond De Vries will be joined by Dr. Brian Zikmund-Fisher, who will serve as an Interim Co-Director. Dr. Zikmund-Fisher is an Associate Professor of Health Behavior and Health Education at the School of Public Health, as well as a Research Associate Professor of Internal Medicine. He has been actively involved with CBSSM and its precursors for over 13 years and has many research collaborations and mentoring relationships with CBSSM faculty, fellows, and affiliates. Dr. Zikmund-Fisher looks forward to helping to grow CBSSM's many research and educational initiatives in the future.

Give me colostomy or give me death! (Aug-06)

Click to decide between death and living with a colostomy. Which would you choose? Are you sure?

Given the choice, would you choose immediate death,or living with a colostomy (where part of your bowel is removed and you have bowel movements into a plastic pouch attached to your belly)?

  •  Immediate Death
  •  Colostomy

Think about what it would be like if you were diagnosed with colon cancer. You are given the option of choosing between two surgical treatments.The first is a surgery that could result in serious complications and the second has no chance of complications but has a higher mortality rate.

Possible outcome Surgery 1
(complicated)
Surgery 2 
(uncomplicated)
Cure without complication 80% 80%
Cure with colostomy 1%  
Cure with chronic diarrhea 1%  
Cure with intermittent bowel obstruction 1%  
Cure with wound infection 1%  
No cure (death) 16% 20%

If you had the type of colon cancer described above, which surgery do you think you would choose?

  • Surgery 1
  • Surgery 2

How do your answers compare?

In fact, past research has shown that 51% people choose the surgery with a higher death rate, even though most of them initially preferred each of the four surgical complications, including colostomy, over immediate death.

Are you saying what you really mean?

CBDSM investigators Brian Zikmund-Fisher, Angela Fagerlin, Peter Ubel, teamed up with Jennifer Amsterlaw, to see if they could reduce the number of people choosing the surgery with the higher rate of death and therefore reducing the discrepancy. A large body of past research has shown that people are notoriously averse to uncertainty. The investigators had a hunch that uncertainty could account for some of the discrepancy. Surgery 1 has a greater number of ambiguous outcomes, perhaps causing people to be averse to it. In an effort to minimize this uncertainty, the investigators laid out a series of scenarios outlining different circumstances and presentations of the two surgeries. For example the research presented some of the participants with a reframing of the surgery information, such as:

Possible outcome Surgery 1
(complicated)
Surgery 2 
(uncomplicated)
Cured without complication 80% 80%
Cured, but with one of the following complications: colostomy, chronic diarrhea, intermittent bowl obstruction, or wound infection 4%  
No cure (death) 16% 20%

The investigators believed by grouping all of the complications together that people would be more apt to chose the surgery with the lower mortality rate, because seeing a single group of undesirable outcomes, versus a list, may decrease some of the ambiguity from previous research.

Although none of the manipulations significantly reduced the percentage of participants selecting Surgery 2, the versions that yielded the lowest preference for this surgery all grouped the risk of the four possible complications into a single category, as in the example shown above.

Why these findings are important

Over the past several decades there has been a push to give patients more information so they can make decisions that are consistent with their personal preferences. On the other hand there is a growing psychological literature revealing people's tendency to make choices that are in fact inconsistent with their own preferences; this is a dilemma. Because the present research suggests that the discrepancy between value and surgery choice is extremely resilient, much research still needs to be done in order to understand what underlies the discrepancy, with the goal of eliminating it.

The research reported in this decision of the month is currently in press. Please come back to this page in the near future for a link to the article.

Read the article:

Can avoidance of complications lead to biased healthcare decisions?
Amsterlaw J, Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Judgment and Decision Making 2006;1(1):64-75.

 

 

 

PIHCD: Geoff Barnes

Wed, May 18, 2016, 4:00pm
Location: 
B004E NCRC Building 16
Geoff Barnes will be presenting on a project with Brian Zikmund-Fisher and Darin Zahuranec on a decision aid for atrial fibrillation.

How old is too old for cancer screening? (Feb-11)

Cancer screening is generally recommended for people over the age of 50. Screening tests, such as colonoscopies, mammograms and PSAs (prostatespecific antigen), can help detect cancer at an early stage andprevent deaths. These screening tests, however, do have risks so,along with their doctor, people need to make a decision about howoften to get screened and when or if one should stop gettingscreened.

Consider the question:

Now, imagine that you were screened for cancer about a year ago and no cancer was found. You and your doctor are talking about when you should come back for screening in the future. Your doctor explains that cancer screening guidelines recommend that you do come back for more screening tests but as you get older, screening for cancer is no longer a good option. Your doctor states that you should follow this recommendation as you age. Now, imagine that you were screened for cancer about a year ago and no cancer was found. You and your doctor are talking about when you should come back for screening in the future. Your doctor explains that cancer screening guidelines recommend that you do come back for more screening tests but as you get older, screening for cancer is no longer a good option. Your doctor states that you should follow this recommendation as you age.

 
Would you plan to stop getting screening tests for cancer at a certain age?
  • Yes
  • No

How do your answers compare?

In a recent study published in the Journal of General Internal Medicine, CBSSM Investigators and Mick Couper and Brian J. Zikmund-Fisher, together with lead author Carmen Lewis (Department of Medicine, University of North Carolina) and several co-authors, explored decisions about stopping cancer screening tests. This study was part of the DECISIONS study, a large survey of U.S. adults about common medical decisions.
 
Recently, the US Preventive Services Task Force recommended against prostate screening for men aged 75 and older, and recommended against routine screening for CRC screening after age 75 and any CRC screening after age 85. Cancer screening for prostate cancer, CRC and breast cancer helps to detect cancer at an early stage when they are easier to treat. However, as a person gets older, the risks of these tests become larger than the benefits.
Data was collected from 1,237 individuals aged 50 and older who reported having made one or more cancer screening decisions in the past 2 years. Participants were asked about their plans of whether or not to stop cancer screening as well as characteristics of themselves and their health care provider.
 
Only 9.8% of people planned to stop getting screened for cancer when they reached a certain age. This percentage varied by type of cancer, age and race of the participant and how much the participant was responsible for the decision apart from their health care professional.
 
Of the 119 people who gave a specific age that they planned to stop getting cancer screening the average age they did or plan to stop was 74.8 for breast cancer, 76.8 for colon cancer and 82.9 for prostate cancer.
 
The study authors concluded that “plans to stop screening were uncommon among participants who had recently faced a screening decision”. They also concluded that further research is needed to understand how people think about the risks and benefits of screening when life expectancy is short and that education around this topic may be beneficial.
 

To learn more about this study, see:

 

Genomics, Health and Society

This special interest group is led by Dr. Scott Roberts who is an Associate Professor in the Department of Health Behavior and Health Education at the School of Public Health as well as the Director and Co-Director of the Public Health Genetics Certificate Program and the Dual Degree Program in Public Health and Genetic Counseling, respectively. Research within this area examines the ethical, social and behavioral implications of advances in genomics. CBSSM serves as a crucial locus for facilitating collaborations across disciplines and units. In fact, several groups across campus have invited us to collaborate on the study of bioethical issues related to burgeoning genomics-related research; these partners include investigators at U-M’s Comprehensive Cancer Center, the Michigan Center for Translational Pathology, and the Division of Pediatric Genetics.

Topics of interest include the following:

 

Do You Know Enough to Take That Medication? (Feb-11)

People in the U.S. make decisions about their health on a regular basis. For example,they are often asked to consider taking medication to treat common health problems, such as hypertension. But do patients have sufficient information to make these decisions? And what factors might influence the knowledge patients have, and their treatment decisions?

Consider this scenario:

Bob is a 52-year-old man who went to see his physician for a routine check-up. Bob’s doctor told him his cholesterol levels were slightly elevated and suggested cholesterol medication. Bob wondered how long he would have to take the medication, and whether there would be any side effects. Please answer the following two questions about cholesterol medications.

When people start taking cholesterol medications, how long is it usually recommended that they take them?

  • less than 6 months
  • 6-12 months
  • 1-3 years
  • for the rest of their lives

How do your answers compare?

Making an informed medical decision about whether to take cholesterol medications depends, at least in part, on understanding how long a medication should be taken and whether there are side effects. CBSSM investigators Angela Fagerlin, Mick Couper, and Brian Zikmund-Fisher recently published an article on patient knowledge from the DECISIONS study, a large survey of U.S. adults about common medical decisions. One main objective of the study was to determine adults’ knowledge about information relevant to common types of medication, screening, or surgery decisions they recently made. Data were collected from 2575 English-speaking adults aged 40 years and older who reported having discussed common medical decisions with a health care provider within the previous two years. Participants answered knowledge questions and rated the importance of their health care provider, family/friends, and the media as sources of information about common medical issues.

People taking cholesterol medications usually should take them for about 3 or more years, and perhaps even for the rest of their lives. A little more than 60% of the study respondents accurately identified the time to take cholesterol medications.

Many people have trouble with this question and do not know that muscle pain is the most commonly reported side effect of cholesterol medications. Only 17% of DECISIONS study respondents were able to answer this question correctly. About 1 in 5 respondents incorrectly identified liver problems as the most common side effect of cholesterol medications.

Overall, the investigators found that patient knowledge of key facts relevant to recently made medical decisions was often poor. In addition, knowledge varied widely across questions and decision contexts. For example, 78% of patients considering cataract surgery correctly estimated typical recovery time, compared to 29% of patients considering surgery for lower back pain or 39% of patients considering a knee or hip replacement. Similarly, in thinking about cancer screening tests, participants were more knowledgeable of facts about colorectal cancer screening than those who were asked about breast or prostate cancer. Respondents were consistently more knowledgeable on questions about blood pressure medication than cholesterol medication or antidepressants.

The impact of demographic characteristics and sources of information also varied substantially. For example, black respondents had lower knowledge than white respondents about cancer screening decisions and medication, even after controlling for other demographic factors. Researchers found no race differences for surgical decisions, however.

The authors concluded by noting that improving patient knowledge about risks, benefits, and characteristics of medical procedures is essential to support informed decision making.

For more information: 

Fagerlin A, Sepucha KR, Couper M, Levin CA, Singer E, Zikmund-Fisher BJ. Patients' knowledge about 9 common health conditions: The DECISIONS survey. Medical Decision Making 2010;30:35S-52S.

 

Megan Knaus, MPH

Research Associate

Megan joined CBSSM in 2014 and has worked on multiple grant funded research projects related to health communication, patient-provider decision making, and health interventions driven by behavioral economics. She currently works with Dr. Brian Zikmund-Fisher on a National Science Foundation grant testing infectious disease communication strategies.

Last Name: 
Knaus

Tanner Caverly and colleagues performed a systematic review to determine how U.S. cancer prevention and screening recommendations present the potential benefits and harms associated with the procedures. They found that 69% of recommendation statements either did not quantify benefits and harms or presented them in an asymmetric manner. They conclude that improved presentation of benefits and harms in guidelines would better ensure that clinicians and patients have access to the information required for making informed decisions.

Caverly TJ, Hayward RA, Reamer E, Zikmund-Fisher BJ, Connochie 2, Heisler M, Fagerlin A. Presentation of Benefits and Harms in US Cancer Screening and Prevention Guidelines: Systematic Review. J Natl Cancer Inst. 2016 Feb 24;108(6). pii: djv436. doi: 10.1093/jnci/djv436.
 

Research Topics: 

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