Effect of physician disclosure of specialty bias on patient trust and treatment choice.
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ABSTRACT:
SUBMITTER: Sah S
PROVIDER: S-EPMC4941435 | biostudies-other | 2016 Jul
REPOSITORIES: biostudies-other
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Effect of physician disclosure of specialty bias on patient trust and treatment choice.
Sah Sunita S Fagerlin Angela A Ubel Peter P
Proceedings of the National Academy of Sciences of the United States of America 20160620 27
This paper explores the impact of disclosures of bias on advisees. Disclosure-informing advisees of a potential bias-is a popular solution for managing conflicts of interest. Prior research has focused almost exclusively on disclosures of financial conflicts of interest but little is known about how disclosures of other types of biases could impact advisees. In medicine, for example, physicians often recommend the treatment they specialize in; e.g., surgeons are more likely to recommend surgery ...[more]
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Project description:Importance:As the clinical workforce becomes more diverse, physicians encounter patients who demean them based on social characteristics. Little is known about physicians' perspectives on these encounters and their effects. This knowledge would help develop policies and best practices for institutions and training programs. Objective:To describe the range and importance of encounters with biased patients and the barriers and facilitators to effective responses. Design, Setting, and Participants:This qualitative study recruited convenience samples of hospitalist attending physicians, internal medicine residents, and medical students from 3 campuses affiliated with 1 academic medical center. Data were collected from 50 individuals within 13 focus groups from May 9 through October 15, 2018. Focus groups were conducted using open-ended probes, audiotaped, and transcribed. Participants used their own definition of biased patient behavior. Each transcript was independently coded by at least 2 investigators. Data were analyzed from May 2018 through February 2019. Main Outcomes and Measures:Major themes associated with types of encounter, importance to the participant, and barriers and facilitators to effective responses were abstracted through the constant comparative approach. Results:Overall, 50 individuals (11 hospitalists, 26 residents, and 13 students) participated; 24 (48%) were nonwhite. At total of 26 participants (52%) identified as women; 22 (44%), as men; and 2 (4%), as gender nonconforming. Reports of biased behavior ranged from patient refusal of care and explicit racist, sexist, or homophobic remarks to belittling compliments or jokes. Targeted physicians reported an emotional toll that included exhaustion, self-doubt, and cynicism. Nontargeted bystanders reported moral distress and uncertainty about how to respond. Participant responses ranged from withdrawal from clinical role to a heightened determination to provide standard of care. Barriers to effective responses included lack of skills, insufficient support from senior colleagues and the institution, and perception of lack of utility associated with responding. Participants expressed a need for training on dealing with biased patients and for clear institutional policies to guide responses. Conclusions and Relevance:In this qualitative study of physicians and medical students, encounters with demeaning patients ranged from refusal of care to belittling jokes and were highly challenging and painful. Addressing biased patient behavior will require a concerted effort from medical schools and hospitals to create policies and trainings conducive to a clinical environment that respects the diversity of patients and physicians alike.
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Project description:Background: Despite being a vital part of medical workforce planning and development, how medical students and graduates choose their career specialty is still not well understood. This study aimed to identify the factors medical graduates consider important influences in their choice of specialty after their first year of practice, and to test the validity of relying on respondent recall to measure changes in specialty choice.Methods: The baseline survey was administered online to all final year students in Ireland's six medical schools. Those who consented to follow-up (n =?483) were surveyed 18?months later (June 2018), during the final month of first year of practice.Results: The baseline survey had a 67% (n =?483) response rate. At the follow-up survey, (n =?232, 48% response rate) the top specialty choices were: Medicine, n =?54 (26%); Surgery, n =?34 (16%); General Practice, n =?28 (13%); Anaesthesia, n =?16 (8%) and Paediatrics, n =?14 (7%). Of the 49 respondents (28%) reporting a change of specialty since baseline, 13 (27%) selected the same specialty in both surveys; of the 121 (69%) reporting no change, 22 (18%) selected a different specialty at follow-up. Over 90% of respondents rated as 'important or 'very important': 'Own aptitude', 'Work-life balance' and 'What I really want to do'. Over 75% rated as 'not at all', or 'not very important' 'Current financial debt' and 'Inclinations before medical school'. When adjusted for sex and age, compared with Medicine, General Practice rated as more important: continuity of patient care (RRR 3.20 CI(1.59-6.41), p =?0.001); working hours/conditions (RRR 4.61 CI(1.03-20.60), p =?0.045) and a career that fit their domestic circumstances (RRR 3.19 CI(1.27-8.02), p =?0.014). Those choosing Surgery rated as less important: patient contact (RRR 0.56 CI(0.33-0.95), p =?0.033) and working hours/conditions (RRR 0.55 CI(0.31-0.96), p =?0.035).Conclusions: The different demographic and motivational profiles by specialty choice are consistent with other studies suggesting a distinct profile for doctors intending to enter General Practice. In addition, our results suggest longitudinal study designs guard against recall bias and so provide more robust medical workforce models to inform and direct recruitment drives and interventions in future medical workforce planning.
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Project description:BackgroundPatient trust in physicians is a critical determinant of health seeking behaviors, medication adherence, and health outcomes. A crisis of interpersonal trust exists in China, extending throughout multiple social spheres, including the healthcare system. At the same time, with increased migration from Africa to China in the last two decades, Chinese physicians must establish mutual trust with an increasingly diverse patient population. We undertook a qualitative study to identify factors affecting African migrants' trust in Chinese physicians and to identify potential mechanisms for promoting trust.Methods/principal findingsWe conducted semi-structured, in-depth interviews with 40 African migrants in Guangzhou, China. A modified version of the social ecological model was used as a theoretical framework. At the patient-physician level, interpersonal treatment, technical competence, perceived commitment and motive, and language concordance were associated with enhanced trust. At the health system level, two primary factors influenced African migrants' trust in their physicians: the fee-for-service payment system and lack of continuity with any one physician. Patients' social networks and the broader socio-cultural context of interactions between African migrants and Chinese locals also influenced patients' trust of their physicians.ConclusionsThese findings demonstrate the importance of factors beyond the immediate patient-physician interaction and suggest opportunities to promote trust through health system interventions.
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Project description:BackgroundMost endocrinologists encounter patients who are dissatisfied with their current hypothyroidism therapy and request combination therapy with either liothyronine (LT3) or thyroid extract.MethodsA survey of American Thyroid Association members was conducted in 2017. Respondents were presented with 13 scenarios describing patients with hypothyroidism and were asked to choose among six therapeutic options. The index patient was satisfied taking levothyroxine (LT4) therapy. Twelve variations introduced parameters that potentially provide reasons for considering combination therapy (presence of symptoms, low serum triiodothyronine concentration, documentation of deiodinase polymorphisms). Therapeutic options included (i) continuing LT4, (ii) increasing LT4, (iii) adding LT3 to a reduced LT4 dose, (iv) adding LT3 to the current LT4 dose, (v) replacing LT4 with thyroid extract, and (vi) replacing LT4 with LT3. Repeated-measures logistic regression analysis was performed to examine both the prescribing of LT4 (options i and ii) versus all other therapies and the choice of continuing LT4 (option i) versus either increasing LT4 (option ii), adding LT3 (options iii and iv), or replacing LT4 with thyroid extract or LT3 (options v and vi).ResultsOf the 389 survey respondents, 363 physicians prescribed therapy for hypothyroidism. For the index patient, 98% of physicians continued current LT4 therapy. However, as the patient scenario incorporated other patient characteristics, physicians opted to increase LT4 dose or prescribe other therapies. The tendency to prescribe alternative therapies was powerfully increased by patient symptoms (odds ratio = 25.6 [confidence interval 9-73], p < 0.0001). Older age and the presence of a comorbidity reduced the likelihood that an alternative therapy was prescribed (p = 0.0002 and <0.0001, respectively). All other characteristics, except athyreotic status, patient sex, and body mass index, significantly increased the likelihood that alternative therapies would be prescribed in multivariate analyses (p < 0.0001).ConclusionsEven with the acknowledged limitations of survey methodology, this analysis appears to show a marked increase in the willingness of physicians to prescribe combination therapy in specific circumstances. If current prescribing patterns do incorporate the use of therapies other than LT4, there is a critical need for more research into the benefits and risks of these therapies.
| S-EPMC6247977 | biostudies-literature
Project description:BackgroundColorectal cancer (CRC) screening is effective but underutilized. Although physician recommendation is an important predictor of screening, considerable variation in CRC screening completion remains.PurposeTo characterize the influence of patient trust in care providers on CRC screening behavior.MethodsData were collected as part of a cluster-randomized CRC screening intervention trial performed in the San Francisco Community Health Network from March 2007 to January 2012 (analysis, Spring 2012). All study participants received a recommendation to complete CRC screening from their primary care provider (PCP). Included participants were aged 50-79 years, not current with screening, and completed the Wake Forest Trust Scale (WFTS) measuring trust in PCPs and doctors in general. Primary outcome was CRC screening completion (colonoscopy or fecal occult blood testing) within 12 months following enrollment. Multivariable association adjusted for race/ethnicity, language, and other sociodemographics was estimated using generalized estimating equations with logit link and binomial distribution.ResultsWFTS response was 70.3% (701). Most participants (83%) were Latino, Asian, or black. Most had income <$30,000 (96%) and public health insurance (86%). Higher trust in PCP was associated with screening completion (OR=1.11, 95% CI=1.03, 1.17), but trust in doctors was not (OR=1.02, 95% CI=0.82, 1.28). Race, language, and other sociodemographic factors were not significant in multivariable analysis.ConclusionsAfter controlling for traditional factors, trust in PCP remained the only significant driver of CRC screening completion in low-income patients. Interventions to promote CRC screening may be improved by including efforts to enhance patient trust in PCP.
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Project description:BACKGROUND:Data are lacking on the proportion of physicians who face malpractice claims in a year, the size of those claims, and the cumulative career malpractice risk according to specialty. METHODS:We analyzed malpractice data from 1991 through 2005 for all physicians who were covered by a large professional liability insurer with a nationwide client base (40,916 physicians and 233,738 physician-years of coverage). For 25 specialties, we reported the proportion of physicians who had malpractice claims in a year, the proportion of claims leading to an indemnity payment (compensation paid to a plaintiff), and the size of indemnity payments. We estimated the cumulative risk of ever being sued among physicians in high- and low-risk specialties. RESULTS:Each year during the study period, 7.4% of all physicians had a malpractice claim, with 1.6% having a claim leading to a payment (i.e., 78% of all claims did not result in payments to claimants). The proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic-cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. The mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics. It was estimated that by the age of 65 years, 75% of physicians in low-risk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties. CONCLUSIONS:There is substantial variation in the likelihood of malpractice suits and the size of indemnity payments across specialties. The cumulative risk of facing a malpractice claim is high in all specialties, although most claims do not lead to payments to plaintiffs. (Funded by the RAND Institute for Civil Justice and the National Institute on Aging.).
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Project description:BACKGROUND:Financial ties between physicians and the pharmaceutical and medical device industry are common, but little is known about how patient trust is affected by these ties. OBJECTIVE:The purpose of this study was to evaluate how viewing online public disclosure of industry payments affects patients' trust ratings for physicians, the medical profession, and the pharmaceutical and medical device industry. DESIGN:This was a randomized experimental evaluation. PARTICIPANTS:There were 278 English-speaking participants over age 18 who had seen a healthcare provider in the previous 12 months who took part in the study. INTERVENTIONS:Participants searched for physicians on an online disclosure database, viewed payments from industry to the physicians, and assigned trust ratings. Participants were randomized to view physicians who received no payment ($0), low payment ($250-300), or high payment (>$13,000) from industry, or to a control arm in which they did not view the disclosure website. They also were asked to search for and then rate trust in their own physician. MAIN MEASURES:Primary outcomes were trust in individual physician, medical profession, and industry. These scales measure trust as a composite of honesty, fidelity, competence, and global trust. KEY RESULTS:Compared to physicians who received no payments, physicians who received payments over $13,000 received lower ratings for honesty [mean (SD): 3.36 (0.86) vs. 2.75 (0.95), p < 0.001] and fidelity [3.19 (0.65) vs. 2.89 (0.68), p = 0.01]. Among the 7.9% of participants who found their own physician on the website, ratings for honesty and fidelity decreased as the industry payment to the physician increased (honesty: Spearman's ? = -0.52, p = 0.02; fidelity: Spearman's ? = -0.55, p = 0.01). Viewing the disclosure website did not affect trust ratings for the medical profession or industry. CONCLUSIONS:Disclosure of industry payments to physicians affected perceptions of individual physician honesty and fidelity, but not perceptions of competence. Disclosure did not affect trust ratings for the medical profession or the pharmaceutical and medical device industry. ClinicalTrials.gov identifier: NCT02179632 ( https://clinicaltrials.gov/ct2/show/NCT02179632 ).
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Project description:Objectives: To survey, analyze, and ascertain the preferences for specialty pharmacy services among patients requiring complex care and to provide evidence to support specialty pharmacy service decision-making in China. Methods: To identify essential service attributes and levels, a review of the literature, discussions with specialty pharmacy managers and a pilot questionnaire were conducted. A D-efficient fractional factorial design was used to generate the discrete-choice experiment (DCE) questionnaire. A face-to-face survey of patients with chronic illness and their families or friends was conducted at three specialty pharmacies in Chengdu and Qingdao, China. A mixed logit model was used for estimation. Results: Six relevant attributes were identified and incorporated into the DCE questionnaire. A total of 417 participants completed the survey (mean age 43 years, 45.1% males), and 32.1% had lung cancer. The conditional relative importance showed that the most critical attribute was "frequency of telephone follow-up to monitor adverse drug reactions (ADRs), "followed by "mode of drug delivery," "provider of medication guidance services," and "availability of medical insurance consultation"; the least important attribute was "business hours." A 1 min increase in time spent led to a 0.73% decrease in the probability that a service profile would be chosen. Negative preferences were noted for ADR monitoring by telephone follow-up once a year (β = -0.23, p < 0.001) and business hours [8:30-20:00 (Monday to Friday), 8:30-17:30 (weekend)] (β = -0.12, p < 0.001). Compared with women, men had a higher preference for service monitoring ADRs once every 3 months. Conclusions: Preference measurements showed that "frequency of telephone follow-up to monitor ADRs" had the most critical impact on decisions, followed by "mode of drug delivery." Specialty pharmacies in China need to take these findings into account to improve their design to increase uptake and patient loyalty.
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Project description:Introduction/objectivesMultiple modes of administration are available for systemic lupus erythematosus (SLE) treatments. This study examined patient and physician characteristics associated with the choice of weekly subcutaneous (SC) injection or monthly intravenous (IV) infusion for an unspecified SLE treatment.MethodsThis was a cross-sectional, US web-based survey using a direct elicitation, stated-preference methodology (HO-16-16706). Two hundred patients and 200 physicians were asked to choose between IV or SC administration in a hypothetical scenario. Pairwise and multivariate analyses estimated the odds ratio (OR) for the likelihood of choosing SC over IV for respondent characteristics.ResultsAmong patients, taking non-steroidal anti-inflammatory drugs increased the likelihood of choosing SC injection (OR 3.884), whilst having SLE-related skin problems, a fear of needles or self-injection, and never needing help around the house decreased the likelihood (OR 0.28, 0.13, 0.12, respectively; all p???0.05). Among physicians, >?95% recommended SC injection for patients who live or work far from an infusion center, prefer SC administration, and never or rarely miss medication doses. Physician characteristics including age and treatment practice also influenced choice.ConclusionsPatient and physician characteristics influence choice of SC versus IV therapy for SLE. These findings might inform shared decision-making, which could lead to improved patient outcomes. Key Points • Data regarding patient and physician preference for different modes of administration of SLE therapy are sparse. • This cross-sectional, US web-based study showed that patient and physician characteristics influence choice of SC versus IV therapy for SLE. • A degree of disconnect exists between how factors influence patients' choice and how those characteristics influence physicians' choice of SLE treatment mode of administration. • The findings from this study might inform shared decision-making, which could improve alignment between treatment choice and patient preferences, treatment satisfaction, adherence, and improved patient outcomes.
| S-EPMC7817604 | biostudies-literature
Project description:BackgroundThe emergence of proprotein convertase subtilisin/kexin type 9 inhibitors offered dyslipidemia patients an alternative to statins for lipid-lowering treatment. Understanding patient and physician preferences for lipid-lowering drugs may promote shared decision-making and improve treatment outcomes.MethodsThis study utilized an online discrete choice experiment (DCE) to assess the relative importance (RI) of six attributes related to lipid-lowering drugs, including frequency of administration, mode of administration, reduction of low-density lipoprotein cholesterol (LDL-C) level, risk of myopathy, risk of liver damage, and out-of-pocket monthly cost. Respondents were recruited from dyslipidemia patients and cardiovascular physicians in China. A mixed logit model and latent class analysis were employed to estimate the preference coefficient, marginal willingness to pay (mWTP), and RI of attributes. Ethical approval has been obtained for this study.ResultsA total of 708 patients and 507 physicians participated in the survey. Patients prioritized the 'risk of liver damage' (RI = 23.6%) with 'mode of administration' (RI = 19.2%) and 'frequency of administration' (RI = 18.8%) following closely. Contrarily, physicians prioritized the 'reduction of LDL-C level' (RI = 33.5%), followed by 'risk of liver damage' (RI = 26.0%) and 'risk of myopathy' (RI = 16.1%). Patients placed a higher value on 'frequency of administration' (p < .001) and 'mode of administration' (p < .001) compared to physicians, while physicians valued 'reduction of LDL-C level' (p < .001) and 'risk of myopathy' (p = .012) more than patients. Physicians exhibited higher mWTP than patients for all attributes except frequency and mode of administration. The LCA revealed three distinct patient classes: focus on oral administration, focus on hepatic safety and frequency and focus on hepatic safety and cost. Likewise, three physician classes were identified: frequency-insensitive, efficacy-focused and safety-focused.ConclusionsThe preferences for lipid-lowering drug therapy differed between patients and physicians in China. Physicians should take into account patients' preferences and provide personalized treatment when they formulate lipid-lowering treatment plans.Patient or public contributionPatients participated in the questionnaire design process. They engaged in a focus group discussion to determine attributes and levels and also participated in a pilot survey to assess the comprehensibility of the questionnaires. Additionally, patients were involved in the DCE survey to express their preferences. The findings of patient preference for lipid-lowering drug therapy will promote shared decision-making and optimize the treatment regimen.
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