While I was reading an issue of New England Journal of Medicine, I came across an interesting perspective article. Usually, I skip these articles and focus on clinical studies, images in medicine and review articles that usually have higher yield information that I can apply to help care for my patients. However, Dr. Jerry Avorn’s article, “The Psychology of Clinical Decision Making- Implications for Medication Use,” caught my attention.
Essentially, he discusses how a lot of clinical decision making in medical education is based on the assumption that both clinicians and patients “behave rationally” meaning that with appropriate information they will make decisions that maximize health benefits and minimize risk of harm. However, my clinical experience has shown me, often on a daily basis, that both patients and clinicians act irrationally.
A relevant example would be the treatment of influenza. A lot of patients are hesitant to get the flu shot but will call my office for oseltamivir (Tamiflu) after the first cough, sneeze or runny nose despite what most clinicians consider to be overwhelming evidence that the vaccine is significantly more effective than Tamiflu.
A 2014 British Medical Journal systematic review looked at the 83 articles which reviewed the potential benefits of Tamiflu. From this review, Tamiflu has good evidence supporting reduced time from onset of illness to first alleviation of symptoms from 7 days to 6.3 days (16.8 hours). When used as a post-exposure prophylaxis agent in patients exposed to the flu, it has been shown to reduce risk of symptomatic flu by 55 percent. There is not evidence to show that it reduces rates of hospitalizations, death, diagnosis of post-flu pneumonia (lung infection), bronchitis, otitis media (ear infection) nor sinusitis (sinus infection) any better than placebo.
Now, let’s compare Tamiflu to the influenza vaccine.
According to the CDC, the influenza immunization (flu shot), has been shown in studies to reduce flu-related hospitalizations for the general population. This impact is even greater in high-risk patient groups such as diabetics (79 percent ) and patients with chronic lung diseases (52 percent). A 2017 study, published in Pediatrics, shows that from 2010-2014, children who received flu shots had a decreased risk of dying from the flu by 51 percent in healthy children and 65 percent in children with underlying medical conditions. There is also an incredibly large amount of information documenting safety of the influenza vaccine in both children and adults.
From reading the above information, it seems like the rational choice would be to get an annual flu shot. However, a large number of patients are still not immunized. According to the National Immunization Survey-Flu (NIS-Flu) and Behavioral Risk Factor Surveillance System (BRFSS), vaccination rates for adults have been approximately 40 percent for adults and 55 percent for children from 2009-2016. This means over 50 percent of adults and almost 50 percent of children fail to get immunized despite the above information being known and readily accessible.
While there is a large amount of research in fields such as behavioral finance, I have not seen anything like this being studied in medicine. I think this issue is only going to become more important as quality metrics (diabetes bundles, BP goals, heart failure bundles, adherence to guidelines) continue to become more important for physician evaluation and institutional accreditations. While there is so much we have yet to learn in the field of medicine, I think there is some low-hanging fruit in discovering why we fail to provide care to the best our knowledge. I’d even be willing to wager that some of the tools used in behavioral finance could be used to nudge patients and clinicians into making better health care decisions.
Samuel Plost is a physician who blogs at the Ever Curious Skeptic.
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