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It's your call: your intuition against the experts' advice (Jan-05)

A respected national organization has released new guidelines. As a physician, would you change your patient's treatment based on these recommendations? Imagine you are a primary care physician taking care of a male patient, Sam, with mildly elevated cholesterol. He doesn't like taking pills and, fortunately, his cholesterol has been good enough that he doesn't need any pills. But now, a respected National Organization has just revised its recommendations, and are urging doctors to treat cholesterol more aggressively, even in people like this patient, who has no history of heart disease or diabetes.

What role should these new guidelines play in your decision?

The guidelines should not be a strong consideration 1       2       3       4        5  The guidelines should be a strong consideration
 
What would you recommend to your patient, Sam?
 
I would... 
 
  • ask him to take a pill.
  • urge him to take a pill.
  • give him information about cholesterol and let him decide.
  • urge him not to take a pill.
  • ask him not to take a pill.

How do your answers compare?

What were some of the things you were weighing when you made your decision? Perhaps you were wondering why the National Organization would recommend taking a pill even when a patient's cholesterol is good enough that they wouldn't necessarily need the more aggressive treatment. You might have found yourself wondering whose interests were reflected in these guidelines. Did the National Organization have some kind of investment in the pill or the pharmaceutical company that produces it? You might have had some doubts about just how much you could trust the guidelines.

Resistance to practicing "cost-effective" medicine

In the past, physicians did what was best for each individual patient in their care, without having to consider cost or having to figure out whether an HMO or accreditation board was looking over their shoulders. But now physicians are put in the awkward position of having to judge whether a particular patient will benefit enough from a specific therapy for that therapy to be cost-effective. It is not surprising that physicians disparage cost-effectiveness in health care, given that traditional medical education teaches that they should not consider the cost of medical interventions when treating individual patients.

Resistance to practicing according to Clinical Practice Guidelines

Clinical practice guidelines, like the one you read about on the previous page, offer a potentially palatable way for physicians to consider the cost-effectiveness of medical interventions. High quality guidelines are based on thorough and systematic reviews of clinical and cost-effectiveness evidence. Still, physicians are often concerned that guidelines are tainted by financial conflicts of interest. The experts who are involved in writing the guidelines are often the same individuals who interact with the pharmaceutical industry.

Why cost-effectiveness and Clinical Practice Guidelines belong together

Investigator Ellen Hummel and CBDSM investigator Peter Ubel were asked by the editors of Virtual Mentor, the online ethics forum of the American Medical Association, to comment on whether clinical practice guidelines ought to incorporate cost-effectiveness information. These investigators begin by acknowledging the resistance to practicing cost-effective medicine. At the same time, however, they argue that including cost-effectiveness information in clinical practice guidelines is an essential way to address physicians' concerns about the kinds of conflicts of interest mentioned above. If cost-effectiveness evidence is presented up-front, physicians wouldn't have as many concerns that the guielines were intended to benefit the industry while sticking the patient with a higher cost. Imagine if on the previous page the guideline had presented evidence that the new, more aggressive cholesterol treatment was still well within accepted cost-effectiveness ratios despite potential conflicts of interest. You might have then better trusted the guideline's recommendation when assessing what to tell Sam.

Including cost-effectiveness information in clinical practice guidelines will enhance the credibility of their recommendations. At the same time, evidence-based guidelines help clinicians recognize the importance of practicing cost-effective medicine with their individual patients. With the help of high quality guidelines, physicians may be encouraged by groups of peers and respected authorities to restrain themselves from pursuing rare benefits for their patients, which is especially important in a time when our current health care system increasingly demands that we become involved with the costs of medical care.

Read the article:

Cost and clinical practice guidelines: Can two wrongs make it right?
Ubel PA, Hummel EK. Virtual Mentor 2004;6:np.

Check out the Ethics Path available to Michigan medical students through the Paths of Excellence (PoE) program. The ethics path provides opportunities for individualized, independent study, combined with field work with CBSSM, and a capstone project in the M4 year.

Click here for more information about the PoE program.

Research Topics: 

Michael Poulin,PhD, has joined the faculty at the University at Buffalo, State University of New York (SUNY) as an AssistantProfessor of Psychology. Dr. Poulin was a post-doctoral fellow at CBSSM for twoyears, under the mentorship of StephanieBrown, PhD.  During this time he was anactive member of the CBSSM research community and a delightful colleague. Dr. Poulin's research focuses on the effects of stress on health and well-being, especiallythe ways people cope with stressful events. He examines how people's beliefsabout the world, including religious beliefs and beliefs about thetrustworthiness of others, influence adjustment to stress.  

Brian Zikmund-Fisher, PhD, a CBSSM investigator and Director of the CBSSM Internet Survey lab, is the principal investigator on an Investigator Initiated Research award from the Foundation for Informed Medical Decision Making that began in October 2008.  The grant, entitled "Learning by Doing: Improving Risk Communication Through Active Processing of Interactive Pictographs," will fund the development and testing of of Flash-based interactive risk graphics that research participants or patients can use to visually demonstrate how likely they believe some event is to occur. Dr. Zikmund-Fisher hopes that people who create risk graphics themselves will have a better intuitive understanding of risk than people who just view static images. Co-investigators on the award include Angela Fagerlin, Peter A. Ubel, and Amanda Dillard.

The novelty of risk and vaccination intentions (May-12)

It's 2009.  Early in the year, a 9-year-old girl from California became the first person with a confirmed case of H1N1 ("swine") influenza in the United States.  Shortly thereafter, the U.S. declared a public health emergency and the World Health Organization declared a phase 6 pandemic (the highest level possible).  By September 2009 a vaccination was developed and was available within a month.

You've been following the news about the H1N1 influenza as developments have unfolded throughout the year, and you feel some concern.  You have been wondering about the risk of coming down with the H1N1 flu yourself and have been thinking about whether you should be vaccinated. 

Thu, May 26, 2011

Raymond De Vries was appointed Professor of Midwifery Science at the University of Maastricht (Netherlands) in November 2010.  As is the custom in European universities, he delivered an inaugural lecture, outlining the educational and research goals of his professorship on May 26, 2011.  It was preceded by a research symposium focusing on risk in maternity care, with speakers exploring the way risk is measured and used by care providers and the way pregnant women respond to assessments of risk they are given. Click here to view a video of his inaugural address, which is in English. Click here for a news article about Dr. De Vries, in Dutch.

Tue, September 20, 2011

The CBS News website recently featured 10 tips to make better decisions about cancer care from U-M’s Angela Fagerlin, Ph.D., associate professor of internal medicine. Below is an excerpt from the article:

Cancer is scary, and doctors sometimes sound as if they’re speaking a foreign language when talking about the disease and its treatment. But “people are making life and death decisions that may affect their survival and they need to know what they’re getting themselves into,” says Fagerlin “Cancer treatments and tests can be serious. Patients need to know what kind of side effects they might experience as a result of the treatment they undergo.”

 

Raymond De Vries is co-author on a new publication in Academic Medicine, highlighting a successful model for collaboration which was developed in the early phases of a grant funded by the Bill & Melinda Gates Foundation nearly five years ago. The Collaborative Health Alliance for Reshaping Training, Education, and Research (CHARTER) project expanded the partnerships between the University of Michigan and several Ghanaian academic institutions to enhance health care provider education and build and/or increase research capacity. One of the early goals of the grant was to establish guiding principles for engagement through a Charter of Collaboration.


Read more about the partnership through UMHS News and the origional PubMed article.

Thu, September 11, 2014

NOVA (on PBS) broadcasted a special episode on vaccines. Brian Zikmund-Fisher was interviewed and prominently featured. Diseases that were largely eradicated in the United States a generation ago-whooping cough, measles, mumps-are returning, in part because nervous parents are skipping their children's shots. Amid the return of vaccine-preventable diseases, NOVA examined the science of immunization, tracked outbreaks, and shed light on the risks of opting out.

The program premired Wednesday, September 10, 2014 at 9 pm/8c on PBS. Watch the full program here.

You can read the press release here.

Research Topics: 
Thu, February 26, 2015

Raymond De Vries, Co-Director of CBSSM,  Kerry Ryan, H. Myra Kim, and Scott Kim are co-authors on a recently published JAMA Research Letter entitled, “Moral Concerns and the Willingness to Donate to a Research Biobank.”  Tom Tomlinson, PhD from MSU is the first author.

Listen here to Dr. De Vries discussing the findings on Michigan Radio's Stateside program.
 

Research Topics: 

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