This headline from September 13, 2005 in the Wall Street Journal Online caught my eye:
Many Ignore Doctor Recommendations on Perceptions of 'Over Treatment'
“More than half of U.S. adults say they've chosen to forgo a treatment recommended by their doctor, including filling a prescription, getting a diagnostic test or undergoing a surgical procedure, because they felt it was unnecessary or too aggressive, a Wall Street Journal Online/Harris Interactive health-care poll found.”
“The online poll of 2,286 adults indicates considerable concern among Americans about the frequency with which patients receive too many or overly aggressive treatments from their doctors: 83% feel undertreatment often or sometimes can result in medical problems among patients, while 72% feel overtreatment contributes to problems.”
There are many aspects of online polling that can be questioned, but it still defines a population of Internet users. The poll went on to ask what the participants thought the physicians’ motivation for overtreatment could be. The results were fairly predictable:
“Physicians' concerns about malpractice (53%), their desire to earn more (45%), and their desire to meet patients' demands (45%) are seen as the main causes of unnecessary care, according to the poll. Another 30% feel misleading information doctors receive from drug and medical-device companies contributes to overly aggressive treatments.”
This type of poll is interesting primarily from the standpoint of recording perceptions of a given population of people. The population, unfortunately, is not defined nor otherwise categorized, so the generalizability of such observations is not known. But the findings are potentially both troubling and optimistic. A number of speculative possibilities exist on both sides.
On the troubling side the results suggest patients may have a lower degree of trust in physicians than physicians believe. Or people may want the suggested tests or treatments but may not be able to afford them.
On the heartening side is that patients may be smarter than healthcare professionals think. They may be fully capable of taking professional opinion or judgment and deciding for themselves what to do. So who’s right? Maybe the individuals really “needed” the test or treatment and will suffer some terrible outcome in the future. Or maybe they were appropriately skeptical of recommendations for tests or treatment that are “at the margin” of benefit, and they made a rational cost-benefit decision.
Of course, the fact that they were answering an online questionnaire says that most likely nothing terrible happened to them from not taking the tests or treatments. There most definitely is a self-selection bias as well as a survival bias in polls such as these.
But here may be the real question from observations such as these:
Is this behavior willful non-compliance? Disobedience? A type of conscientious objection?
Or could this actually be satisficing in action?
The term satisfice was coined by Herbert Simon in 1957 and is a concept that may have great relevance in healthcare decision making. The Abramson Center For the Future of Health has been studying the applicability of satisficing in this setting through its info-gap research.
Satisfice means that an individual seeks a result that is “good enough” rather than the optimized result, or what is sometimes called maximal utility.
“Good enough” implies that more than the utility or operational factor of the suggested treatment or test has been taken into account by the patient. Other factors such as goals, beliefs, priorities, needs, desires, risk tolerance, tolerance of uncertainty of outcome, and emotions such as fear are taken into account in a decision to follow recommendations from a health professional. The process is multi-dimensional.
When care is delivered “at the margin” of benefit there is plenty of room for Pareto’s principle, the famous 80-20 rule, to come into play. People often accurately figure that they can get most of the benefit without paying the potentially high price of trying to get to “best.”
People also have instinctual knowledge of when they are really sick and should do something and when they don’t really have to act. Of course, this instinct is countered by our best defense mechanism, denial. No one said this was simple.
