To Tell the Truth…or Not
The Influences Behind Medical Decisions

Let’s say your patient is a 55-year-old woman with stable severe angina caused by coronary artery disease. Even though she takes the maximum amount of medication, she still has chest pain with low levels of physical activity. Her insurance company won’t pay for bypass surgery unless her symptoms get worse. What would you do?

Peter A.Ubel Photo: Marcia Ledford

In a recent random survey of 890 physicians using similar scenarios, 11 percent of doctors said they would misrepresent the patient’s condition to obtain HMO approval for surgery or additional procedures. Seventy-seven percent said they would appeal the decision, and only 12 percent said they would accept it. The survey was conducted by Peter A. Ubel, M.D., an associate professor of internal medicine in the U-M Medical School and a research investigator at the Ann Arbor Veterans Administration Medical Center.

Ubel directs the Program for Improving Health Care Decisions, a new research program funded jointly by the U-M and Ann Arbor’s Veterans Administration Medical Center. “Our goal is to conduct interdisciplinary research on how patients, clinicians and policymakers make health care decisions,” says Ubel.

“In medical school, we learn about the Krebs cycle and Latin names for every point where muscle attaches to bone — information we rarely use again,” he says. “But we learn almost nothing about how humans make decisions, especially when they are overwhelmed with information.”

As an example, Ubel cites a woman who must decide between several treatments for breast cancer. “As her physician, should I tell her what to do or suggest a second opinion? What is the best way to explain her treatment options? Should I use numbers or graphs? How do I know she understands what I’m saying?”

When psychologists study decision-making, Ubel says the research subjects are usually undergraduates or consumers deciding which product to purchase. “We want to focus on how people make medical decisions, such as what motivates a physician to appeal a managed care decision?”

In his survey, Ubel discovered that the severity of the patient’s condition and the “hassle factor” — the amount of time required by the appeals process and the likelihood of a successful appeal — were all directly related to a physician’s willingness to deceive the insurance company. The sicker the patient and the greater the hassle factor, the more likely the physician was to lie.

“It’s important to not see this as an us-versus-them issue,” says Ubel. “We ought to see it as how to find the best way to give people appropriate care, while restraining the use of expensive tests that bring small benefits. The more it is seen as us-versus-them, the more doctors will begin playing by their own rules. If that happens, it is everyone’s problem.”

Angela Fagerlin, Ph.D., a research investigator in the U-M Medical School, is a co-author on the study, along with Rachel M. Werner, M.D., now a research fellow at the University of Pennsylvania, and G. Caleb Alexander, M.D., now a research fellow at the University of Chicago.

—Sally Pobojewski

For more information on the Program for Improving Health Care Decisions or to participate in their “Decision of the Month,” go to: www.med.umich.edu/pihcd