When Doctors Disagree
Different opinions started to come in shortly after Malcolm Farrell* was diagnosed with prostate cancer. The 64 year old landscape architect was nearing retirement and had never felt better when a routine screening test for prostate cancer, the PSA, turned up slightly elevated. An ultrasound showed a small cancer which was confirmed by a biopsy.
The specialist who performed the biopsy, a urologist—a surgeon specializing in problems of the urinary tract and prostate—recommended that Malcolm undergo radical prostate surgery. He told Malcolm that the operation would give him the best shot at long term survival.
A few days later Malcolm came to my office for another opinion. He’d heard about some of the side effects of radical prostate surgery such as impotence and incontinence and he wondered if there were other options. I told him that there were major differences of opinion among doctors about the best approach to prostate cancer.
For men over 70, many experts recommend so-called watchful waiting—a euphemism for doing nothing. The reason this non-aggressive approach is often favored is that prostate cancer is usually so slow growing. In fact, most men who develop prostate cancer will die of other causes before they ever get symptoms of the cancer.
The other option is X-ray therapy. Radiation is considered less invasive than radical prostate surgery since an operation isn’t required but it still can cause significant side effects. Many experts consider it to be as effective as surgery, and in fact, when Malcolm later consulted a radiation specialist she recommended X-ray therapy.
I stressed to Malcolm that there was no rush to make a decision. Even though the cancer was just detected it had probably already been slowly growing for several years. Delay of a few weeks to make a decision wouldn’t be dangerous and if it helped him make the best decision it would be well worth it. I suggested he go to the library and do a little reading on the subject. I also recommended a couple of recent review articles that had appeared in leading medical journals.
Why Do Doctors’ Opinions Differ?
The major reason that opinions differ so much is that doctors do. Even for conditions for which there’s much less disagreement than there is for prostate cancer, you could see three different doctors and easily walk away with three different points of view.
Here are some of the ways that doctors differ:
- Philosophy of Practice. Some doctor are very aggressive in applying therapies which might help but which also entail risk. Other doctors worry more about the potential side effects of highly invasive treatments, like radical prostate surgery, particularly when the evidence of their effectiveness is weak. In general, surgeons are more aggressive than non-surgeons but even surgeons vary in their approach.
- Specialty. If you think about it, it makes sense that surgeons would be more aggressive. They chose to go into that specialty instead of, say, cardiology because they like to operate. It stands to reason if you consult a surgeon you are likely to end up with a recommendation to operate. Doctors are also more likely to recommend an option that they have more experience with.
- Knowledge. Some doctors
simply know more than others. Look for one who is board-certified
(You can find out by calling the American Board of Medical Specialists
at 1-800-776-CERT). Such factors as where the doctor trained
and whether the doctor has an appointment to a local medical
school also tend to reflect knowledge.
One area that deserves special mention is whether the doctor has stayed current with scientific advances. Medical information is expanding at a rate that no doctor can keep up with completely. Some, however, do a much better job than others. A doctor may not recommend an approach simply because he or she hasn’t heard of it. - How They Are Paid. We’d like to think that money would have no effect on what a doctor recommends but sadly that’s not true. This isn’t to say that all doctors are greedy business people, but money has a subtle way of coloring a doctor’s judgment. Keep in mind that a surgeon recommending a operation, for example, may stand to make thousands of dollars if you have it.
One of the main problems in sorting out differing opinions regarding the best treatment is that we often don’t have enough good scientific data to say which approach is best. In the case of prostate cancer, good studies are now under way but the results won’t be available for another decade. In the meantime, treatment decisions will have to be made using the best information available.
Keep in mind, too, that just because doctors disagree doesn’t mean one of them is wrong. There are reasonable differences of opinion and often more than one approach will work. On the other hand, just because doctors agree doesn’t mean they’re right either (or that what they recommend is right for you). In the 1960s most surgeons would have agreed that routine tonsillectomies were a good idea. We now know better.
Try following the general strategies listed below to figure out the best course of action when your doctors are giving you conflicting advice:
- Learn as much as you
can about your diagnosis and the recommended treatments. The
more you know, the smarter questions you’ll be able to ask,
the better you’ll be able to evaluate what a doctor says
and the more you’ll be able to tell if that doctor is up-to-date.
Resources includes books, magazine articles, on-line services
and consumer groups.
The evening after coming to my office, Malcolm Farrell visited his local library. He read the articles I suggested but he didn’t stop there. With the help of the librarian he searched a medical database to learn even more about his condition. He discovered, for example, a promising experimental treatment for prostate cancer in which tiny radioactive “seeds” are implanted in the organ. While he didn’t end up opting for that treatment, learning about it broadened his understanding of prostate cancer. - Don’t feel pressured
to decide right away. At times you may not have a choice but
in most non-emergency situations the delay of a couple of weeks
in making a decision is not critical. Some people go along with
treatments or tests they really don’t want because they
sense their physician favors it. It can be beneficial to get
out of the glare of the doctor’s office to make your decision.
My recommendation is to collect yourself, do a little reading, talk things over with your family and loved ones and make your decision. If what you decide goes against the doctor’s advice, you may want to bring a supportive family member along with you on your return appointment so that you don’t end up agreeing to sometime you don’t want. - Ask the doctors why they feel the way they do. If you can understand the rationale for each doctor’s recommendation—and not just the recommendation itself—you’ll be in a must better position to evaluate it. By getting below the surface you can gain insight into the doctor’s philosophy of practice. Is there scientific data behind the advice or is it based on personal experience? What would happen to you if you didn’t do what is recommended? Would a delay be harmful?
- Ask each doctor to critically evaluate the differing opinions of his or her colleagues. One doctor may spot weaknesses in another’s reasoning that might not have occurred to you. Physicians may also differ in their assessment of the value of a particular treatment. Try to get each one to write down his or her thinking and show it to the others. Doctors may be able to explain things in a language a colleague will understand better than you can.
- Examine the financial
incentives. In sorting out a doctor’s recommendations it
pays to know where the financial incentives lie. With traditional
insurance the more a doctor does, the more the money flows. This
reimbursement system was in part responsible for the millions
of unnecessary operations—such as hysterectomies and tonsillectomies—that
were done in the last several decades in this country. It stands
to reason—and studies confirm—that when a doctor stands
to profit by recommending a test or treatment he or she is more
likely to do so.
These days, Health Maintenance Organizations (HMOs) and other managed care plans encourage doctors to keep costs down. In fact, under managed care a physician’s income is often directly proportional to how little he or she does. Bonus plans reward doctors who order fewer expensive services like mental health care or hospitalizations. Under some so-called capitation plans (literally by the head), physicians receive a flat monthly fee per patient; the cost of every MRI scan, referral to a specialist or day in the hospital comes directly out of the doctor’s check. The result is that doctors in managed care may be more likely to advise against costly interventions that might benefit you. - Get a third opinion.
In obtaining a third opinion it’s usually a good idea to
consult a doctor unaffiliated with either of the other doctors.
It’s also sometimes beneficial to consult a doctor in another
specialty. For example, if heart surgery is recommendation by
a cardiovascular surgeon, consider consulting a cardiologist,
a non-surgeon who also specializes in the heart.
Given the financial incentives in HMOs against providing expensive services it is often a good idea—if you can afford it—to get an opinion from a doctor outside of the plan. Under some HMO contracts doctors are forbidden to advise you of medically viable alternative treatments that the plan doesn’t want to pay for. Doctors who violate these so-called “gag rules” risk being thrown out of the HMO. If you fear you may not be getting the whole story, the best solution may be to see a doctor who can speak unfettered. - Go with your gut. Ultimately
many medical questions have no right answers. Decisions often
must be made on incomplete information. Get as much data as you
can, talk with your friends and family, but in the end, you’ll
have to do what feels best to you.
Remember that many medical choices hinge more on value judgments than on science. Is it a shot at living longer worth it if it means you’d have to live with serious side effects of treatment? The answer is not strictly medical. It depends on what’s more important to you: the length of your life or its quality.
Since you are the one who will have to deal with the consequences of any medical treatment, it ought to be your values—not your doctors—that determine what is done. Of interest, this assertion has been validated scientifically.
Malcolm Farrell ended up choosing traditional radiation therapy for his prostate cancer. He decided that he couldn’t just “watchfully wait” and that the potential side effects of radical prostate surgery were more than he was ready to risk. X-ray therapy seemed like the best compromise.
By doing his homework, Malcolm was able to make the decision that best reflected his own personal values. He also felt empowered. It’s true that his urologist was not pleased with Malcolm’s choice. It’s not the doctor, however, that has to live with the results—it’s Malcolm—and he feels great.
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