A second opinion
Tuesday, February 24 2009
You might have seen one of the many news reports about the study of colon cancer patients and “information-seeking behavior”. Here’s Reuter’s entry:
More patient information may not lead to the best care
By Anne Harding
NEW YORK (Reuters Health) – Colon cancer patients who seek out more information about their care are more likely to be prescribed cutting-edge, expensive medications that aren’t necessarily the best drugs for them, new research shows.
The study’s authors looked a specific targeted therapy (TT) designed for certain kinds of cancer, and whether information-seeking patients were more likely to receive the TT even if they didn’t have the right sort of cancer. Of course, the TT is expensive, so in patients with the wrong kind of cancer it’s probably a lot of money wasted. And, of course, the authors found that information-seeking patients were more likely to receive the TT. So, great – now we all know that patients really are too stupid to process all that sophisticated medical information, just like our doctors have been telling us. Right? Well, no:
When the researchers looked at individual sources, they found that Internet use, newspaper or magazine use, or consultation with another health professional increased a patient’s likelihood of having heard about targeted therapy, while those who sought information from another health professional were more likely to report receiving it. [emph. mine]
Here’s how the study itself presented that result:
Internet use (OR, 2.88; 95% CI, 1.40-5.94) and newspaper/magazine use (OR, 3.44; 95% CI, 1.34-8.84) were associated with hearing about TT. Seeking information from nontreating physicians was associated with hearing about TT (OR, 1.95; 95% CI, 1.03-3.68) and receiving TT (OR, 2.64; 95% CI, 1.16-5.97).
So patients who sought information from the internet, newspapers, or magazines were no more likely to receive the expensive, wasteful medicine – just more likely to have heard of it. Only the patients who sought information from “nontreating physicians” got the TT; that is, only the patients who got second opinions from other doctors. The problem isn’t the patients: it’s the “nontreating physicians”.
I think there are a couple of things going on here: first, patients who get second opinions are more likely to convince their “treating physician” to give them the wrong medicine. If you tell a doc, “I read about TT online”, most won’t even hide their contempt; but if you tell Dr. A, “I saw Dr. B, who told me about TT” – then Dr. A sees a risk you’ll bail and head to Dr. B. The risk is particularly acute for oncologists, most of whom get paid for the drugs they dispense - so both docs have a strong incentive to do so if they think they can get away with it.
The second part of the problem is the pharmaceutical companies; they spend a lot of money convincing doctors to prescribe meds off-label. Dr. B probably heard about the TT from a pharm rep – usually a cheerleader or beauty queen – and not from any impartial scientific source. Yet somehow this is the information-seeking patient’s fault.
Nothing about this study should keep you from researching your disease and treatment options, but be aware that the pharmaceutical industry’s marketing efforts also affect patients directly; not that we’re wined and dined by beauty queens, but the industry spends a lot of money putting out information that’s not necessarily helpful to us. It’s not just ads in magazines, but also a lot of press releases that make their way into articles direct from the manufacturers’ press departments. Online, pharm companies spend a lot of money developing and sustaining ersatz “communities” for people with a particular disease, all of it designed to drive patients to the sponsoring company’s top-of-the-line drug. Meanwhile, the most reliable information – peer-reviewed studies – gets the double whammy: not only are almost all studies hidden behind paywalls, but they’re written in technical language that’s inaccessible to the nonspecialist reader. So it’s pretty easy to understand how patients might get misled: the reliable information is inaccessible, and the accessible information is unreliable.
Instead of blaming patients for taking responsibility for their care, the study’s authors would do better to look at the quality and source of the information patients get, and the ways that information might be improved; for example, it would help if journals made available plain-language, extended abstracts of their articles online. But until such improvements occur, it’s a mistake to blame patients for a problem created by the medical profession.
Ooncologists get paid for the drugs they dispense? Do other doctors get paid like that also? How would a patient know that?
@m.-
I didn’t know until I read it in a post on HealthBeat: http://www.healthbeatblog.org/2009/01/a-very-open-letter-from-an-oncologist.html .
I don’t think most doctors get paid like this, but I think some of the newer biologics that require in-office infusion – like Remicade – might have a similar payment model for doctors.