4 Nonclinical Components of Surgical Decision Making

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4

Nonclinical Components of Surgical Decision Making

Jo Ann Broeckel Elrod, Farhood Farjah, and David R. Flum

ers as well. Whether surgeons stopped performing the operation because of lack of reimbursement or as an acknowledgement of scientiﬁ c uncertainty is unclear. It is clear, however, that the sharp decline in the number of procedures was temporally related to CMS intervention. Subse- quent CMS policy partly limited surgical decision making because reimbursement was limited to eligible patients and surgeons.

Professional organizations can also play a role in decision making by effectively regulating surgeon-directed clinical practice in the setting of clinical uncertainty. For example, through educational and advisory statements, the Ameri- can Society of Colorectal Surgeons strongly in - ﬂ uenced its membership to avoid performing laparoscopic procedures for colorectal cancer despite the use of these interventions by many surgeons for benign disease. There was no similar

“prohibition” by thoracic surgical professional organizations in 1994, and these circumstances may have “permitted” surgeon-level, non- evidence–based decision making to ﬂ ourish with LVRS. The case of LVRS reveals that many nonclinical factors involving patients, surgeons, and the practice environment can inﬂ uence surgical decision making.

4.1. Methodology for

Evaluating Nonclinical Factors of Decision Making

Previous investigations of nonclinical factors inﬂ uencing clinical decision making have used qualitative or semiquantitative research meth- Examining surgical trends before the National

Emphysema Treatment Trial (NETT) demon- strates the importance of nonclinical determi- nants of care. The number of lung volume reduction surgery (LVRS) claims increased dra- matically after 1994 despite the fact that there was considerable uncertainty in the available evidence base.¹ Favorable media reports and testi- monials from patient advocacy groups may have infl uenced both patient and surgeon attitudes about LVRS.² Some surgeons felt that investigations prior to the NETT demonstrated clear and dramatic improvements in quality of life, suffi - cient to justify Medicare reimbursement for the procedure.³ Accordingly, they believed the NETT was a form of coercion because patients who refused to enroll in the study would not have fi nancial coverage of their LVRS or receive the operation from a NETT surgeon. Furthermore, even if patients enrolled, the study deprived half of them a procedure with “established” benefi ts.

Surgeons less comfortable with this level of scien- tifi c uncertainty may have decided against performing the procedure. Nonsurgeon observers proposed that surgeons were motivated by fi nancial gains, as the procedure was relatively inex- pensive and reimbursement was generous.² In addition to potential patient and surgeon infl u- ence, third-party coverage had an effect on decision making as evidenced by the dramatic decrease in the number of operations upon sus- pension of Medicare reimbursement in December 1995.⁴ Because many third-party payers base their coverage plans on Centers for Medicare and Med- icaid Services (CMS) guidelines, this policy likely affected many non-Medicare patients and provid-

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odologies – such as surveys, case vignettes, and decision-analytic modeling – all of which have important methodological limitations.⁵ Clinicians often fi nd qualitative research (i.e., focus groups and key informant interviews) diffi cult to interpret because the question of gener- alizability is more problematic and because this approach does not test hypotheses. Rather, qualitative research helps develop hypotheses that may then be evaluated using semiquantitative evaluations such as surveys. Surveys are diffi - cult to interpret because of their limited gener- alizability to those who respond, the degree to which the question being asked is understood by the respondent, and, in the case of physician surveys, the extent of socially normative re - sponses. Socially normative responses occur when members of a group provide “acceptable”

answers to questions when the “real” answer would generate negative social judgments. These socially normative answers can also occur in the setting of anonymous surveys but are more common when the individuals are identiﬁ ed. In quantitative evaluations of these issues, such as in a prospective cohort that includes data on beliefs and attitudes of the surgeon and patient, the number of variables of interest and potential for confounding may be overwhelming. Methods less familiar to surgeons, such as the factorial experimental design, may partly overcome these obstacles. Factorial design allows comparisons of differential groupings of categorical variables.

For example, ﬁ ve dichotomized variables have 32 (2⁵) unique groupings that one can analyze using hierarchical logistic regression. In essence, factorial design can estimate the individual and combined effects of many variables, allowing some control of confounding, and may facilitate studies trying to quantify the inﬂ uence of clinical and nonclinical variables. The complexity of the calculations rises with the number of variables and combinations of variables, and thus even this study design has practical limits in terms of the number of variables it can analyze. Of greatest importance to the surgeon interested in assessing this complicated line of research is the need to collaborate with behav- ioralists and biostatisticians with relevant knowledge and experience in alternative research methods.

4.2. Surgeon Factors Related to Clinical Decision Making

As demonstrated in the LVRS example, the clinical decision-making process appears to be inﬂ u- enced by surgeons factors. These factors include the surgeon’s tolerance of uncertainty, how willing they are to take risks in clinical care, the demographic characteristics of the surgeon, and their level and type of training.

4.2.1. Impact of Risk-Taking Attitude on Clinical Decision Making

Because clinical decisions are made under conditions of uncertainty, reactions to uncertainty and attitudes toward risk taking may have important implications on clinical decision making. There is a limit in our understanding of the degree to which this issue inﬂ uences surgical care.⁶ Several investigators have developed instruments to assess risk taking among physicians. Nightingale and colleagues^7–9 have developed a two-question test that has been frequently used to assess the degree to which physicians view themselves as risk seeking or risk averse. In Nightingale’s study, respondents’ willingness to gamble for their patients in both the face of gain and in the face of loss is measured. Those who refuse to gamble in the face of loss are considered risk averse. The ﬁ rst question:

(1) Choose between two new therapies for a healthy person:

(A) 100% chance of living 5 years more than the average person

0% percent chance of living 0 years more than the average person

Or

(B) 50% chance of living 10 years more than the average person

50% chance of living 0 years more than the average person

If the physician selects A, there is a moderate gain and no chance of failure. If they select option B, there is a chance for signiﬁ cant gain, but also a risk of complete failure. The second question is stated in a similar manner, but evaluates the willingness to accept loss for the patient:

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(2) Choose between two new therapies for a sick person:

(A) 100 % chance of living 5 years less than the average person

0% chance of living 10 years less than the average person

Or

(B) 50% chance living just as long as the average person

50% chance of living 10 years less than the average person

Answer A minimizes loss while answer B sub- jects the patient to a smaller risk of great loss and a possible risk of no loss. The same question is posed in two different ways to determine a person’s willingness to gamble in the face of gain (the ﬁ rst case) and in the face of loss (the second case). One set of studies^7–9 performed by Nightin- gale examined physicians’ risk preferences and the relationship of such preferences to laboratory test usage, critical care decision making, and emergency room admissions. Although no sig- niﬁ cant association was found between the item

“dealing with a gamble in the face of gain” and resource utilization, in all three of Nightingale’s studies, a signiﬁ cant correlation was found between resource utilization and risk preference in the face of loss. The more often physicians chose the second gamble, the more likely they were to utilize additional medical resources to rule out uncertain conditions than those who chose the certain outcome. Therefore, when faced with possible loss, the physician preferred to minimize loss and fail in half of these attempts than accept a certain loss. Other authors¹⁰ have found that the “fear of failure” paradigm in risk taking is less consistent but varies based on the mode of testing¹⁰ or across different cultures.¹¹ They also found that physicians who chose to gamble in the face of loss were also more likely to order more testing procedures.

4.2.2. Surgeon Age

Although little data exist on the extent to which surgical decision making is related to risk taking behavior and comfort with ambiguous situations, a recent study by Nakata and colleagues¹² explored the relationship between risk attitudes and demo-

graphic characteristics of surgeons and anesthesiologists. The authors distributed a survey on clinical decision making and expected life years to 122 physicians in Japan. Participants were asked to read a brief scenario designed to produce certainty equivalents for two gambles, one framed as though the respondent were a patient (of the participant’s same age) and the other framed as though the respondent were a physician. Both scenarios ask the respondent to state their willingness (yes or no) to undergo a treatment with a success rate of 80% (i.e., the probability of failure is 20%) with the assumption that they will live for 20 years if the treatment is successful but will die immediately if the treatment fails. The scenario also states that they will be guaranteed to survive 18 years if they do not choose the treatment. The questions were repeated with 2-year differences in expected longevity. Based on the certainty equivalents from the responses, participants were defi ned as risk averse, risk neutral, and risk seeking. Results from the 93 physicians who completed the questionnaire (38 anesthesiologists and 55 surgeons) showed no signifi cant differences in the number and percentage of risk seekers between groups. Comparisons by gender and specialty did not reveal any signifi cant differences in risk preference, nor was risk attitude affected by how the question was framed (as a physician or patient). However, results did indi- cate that the physician’s age was a statistically signifi cant predictor of risk attitude. Specifi cally, the older the physician, the more risk averse they were. The authors interpreted this to mean that based on experience and judgment, older physicians may shy away from risk and younger physicians may be more willing to gamble.

4.2.3. Surgeon Gender

Clinical decisions may also be affected by surgeon demographics, such as physician gender, and, given the paucity of female thoracic surgeons (2.2% of all thoracic surgeons reportedly are female¹³), this may be a signifi cant issue for this fi eld. Several studies have documented the varying communication styles of male and female physicians.¹⁴ Specifi cally, female clinicians are more likely to actively facilitate patient participa- tion in medical discussions by engaging in more

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positive talk, more partnership building, question asking, and information giving.^12–16 Female physicians also tend to be less dominant verbally during clinic visits than male physicians,¹⁴ and, although patients of female physicians talk pro- portionately more during a medical visit than do patients of male physicians, female doctors engage in discussion more with patients than male doctors.¹⁶ While female doctors spend more time with their patients,¹⁷ this difference may be better attributed to gender distribution and health status of their patients. Women physicians tend to see more female patients and female patients tend to have longer medical visits than males.¹⁸ Furthermore, because female physicians engage in more discussion of emotional and psy- chosocial issues than male clinicians,¹⁶ it has been hypothesized that female doctors are more responsive to the nonclinical components of decision making that derive from the patients.¹⁴

Clinical decision making with regard to cancer screening is also affected by physician gender.

Speciﬁ cally, women patients of female physicians have higher rates of screening by Pap smear and mammography than patients of male physicians.¹⁹ It is unclear how these gender differences impact decision making in thoracic surgery but they may be relevant in the comparative use of screening and staging techniques for thoracic malignancies and other entities.

4.2.4. Impact of Training on Clinical Decision Making

Surgeon specialization has been studied in the context of mortality, and specialty training has been shown to predict postoperative outcomes among high-risk operations.²⁰ For example, Dimick and colleagues²¹ found that specialty board certifi cation in thoracic surgery was inde- pendently associated with lower operative mortality rates after esophageal resection in the national Medicare population (from 1998 through 1999). Goodney and colleagues²² showed that board-certifi ed thoracic surgeons have lower rates of operative mortality with lung resection compared to general surgeons, although they noted that surgeon and hospital characteristics, in particular volume, also infl uenced a patient’s operative risk of mortality. Some of this effect

may be mediated by the volume of procedures performed by differently trained surgeons, but process of care variables are often different in specialty trained surgeons and it is very likely that other components of decision making are inﬂ uenced by training factors.

Surgeon specialization, however, has not been rigorously studied as it relates to clinical decision making. Training and specialization undoubtedly impact decision making by physicians.

Specialty-trained thoracic surgeons may be more recently trained than non-specialty–trained surgeons and therefore may include more recently developed evidence-based protocols in their decision making. Conversely, after a lifetime of experience, older surgeons (more likely to be non- fellowship–trained) are undoubtedly infl uencing decision making through a separate group of experience-based care guidelines. It remains to be seen if subspecialty-trained clinicians are more risk seeking in their treatment options given their additional training. The maxim “a surgeon with lots of experience got that way by having lots of bad experiences” underlies the way that collec- tive professional experience infl uences decision making. While most try not to unduly infl uence their behavior by their last unsuccessful outcome, the lessons learned from unfortunate decisions must infl uence surgeon decision making. The potential effects of this infl uence may include the way we discuss risk with patients, or may consist of modulation of risk taking if we have had a recent bad outcome related to prior risk taking.

The interesting issue related to past experience is how little we understand about how it affects clinical decision making. If one goal of quality improvement (QI) activities is to limit variation then we must better understand and regulate the inﬂ uence of non-evidence–driven factors, such as past experiences, if we are to achieve that goal.

4.3. System Factors

Clinicians do not make decisions in a vacuum.

Systems including colleagues, employers, payers, healthcare systems, and QI staff all review our decision making and thereby inﬂ uence it. These system factors may be as limited as a group of colleagues with whom we share decision making.

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These “coverage” partners may inﬂ uence our decision making in that they share the conse- quences of decision making through “on-call coverage.” Sometimes decisions about who re - turns to the operating room to rule out problems (rather than taking a wait-and-see approach) or what types of diagnostic testing we obtain to evaluate for potential problems are inﬂ uenced by the day of the week, cross-coverage patterns, and expectations for on-call responsibilities.

Organized health systems may also infl uence decision making because signifi cant variability in process and outcome of care also has important implications for payers and hospitals. For example, in some health maintenance organizations (HMOs) there are rigid guidelines for the treatment of patients that may limit individual surgeon decision making. This can be as innocu- ous as the limits some HMOs have put on formu- laries of drugs to infl uence the use of drugs for our patients. In other systems the types of devices surgeons can use are limited, thereby limiting surgeon autonomy in decision making. Hospitals have also been expanding the use of guidelines, treatment pathways, and care plans. These are all interventions aimed at limiting decision making variability. The extent to which these approaches are used and effective in limiting hospital stay, the use of resources, and variability in care dem- onstrate the impact of nonclinical components of care in systems that do not have such interventions.

4.3.1. Characteristics of the Environment and Clinical Decision Making

For over a decade, surgeons in the Veterans Administration hospitals have participated in a systematic data-gathering and feedback system of outcomes after major surgery. The National Surgical Quality Improvement Project (NSQIP) works to decrease variation in clinical outcomes by demonstrating to surgeons when their center is an “outlier” in performance. This system allows hospitals to target QI activities that may inﬂ u- ence components of care and may also inﬂ uence surgeon decision making. A potential unintended consequence of any ranking system is that it may also impact a surgeons’ willingness to operate on patients who have particularly high risk of

adverse outcome, especially if the risk adjustment strategy is not considered adequate. This inﬂ u- ence on surgical decision making needs further investigation to determine its importance.

Other system factors that cannot be excluded relate to the value of surgeon performance to a system. For example, in systems such as the Canadian National Healthcare System and in Scandinavia, where surgeons are given a ﬁ xed salary and procedure volume is not tied to reimbursement, there is a considerably lower use of operative procedures and considerably less population-level variability in the use of procedures.

Clearly, this is a health system inﬂ uence on surgeon decision making and it clearly challenges the notion that surgical decision making is driven exclusively by clinical factors.

4.4. Social Factors

4.4.1. Patient Interest

In a more paternalistic era, decision making was driven exclusively by the physician, but patient autonomy has become a central feature of modern medical ethics. Informed patients will bring to the decision-making process a perspective that sometimes completely afﬁ rms the surgeon’s primacy in decision making but other times may challenge this primacy. Empowered patients may bring to the decision-making process their interest in quality of life and functional outcomes that may be less important in physician-directed decision making. Alternatively, helping patients develop a realistic risk assessment of an intervention can be challenging, especially in the setting of unfamiliar diagnoses, medical terms, and prognostic information. Acknowledging that the patient may be a major determinant of care decisions is an important step to understanding the variability we see in clinical care. However, it also raises the challenge of adequately informing our patients about the components of decision making without overwhelming them. The challenge is extended by the use of web-based resources that may both inform and misinform patients and the unique experiences patients, their loved ones, and friends may have had with similar conditions.

One interesting evolution in our understanding of nonclinical factors that inﬂ uence decision

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making comes from research in shared decision making in cancer patients. Decision aids have been developed to improve communication between the cancer patients and the physicians and to allow patients to express their preference for treatment by providing information on the outcomes relative to their health status. The interactive nature of these tools allows patient values and interests to be incorporated into decision making. For example, decisions about adjuvant therapy that include a discussion of the risks of chemotherapy (e.g., hair loss) may not be relevant to certain patients (e.g., patients who have no hair) while for others it may be an outcome that they are not willing to tolerate even if it has implications for survival. While some may disagree with the decisions that patients make, acknowledging their autonomy and empower- ment may help in the delivery of care that is appropriate to each patient and meet each patient’s needs. These decision aids have been quite successful. In fact, Whelen and colleagues,²³ in a randomized trial of 20 surgeons and 201 breast cancer patients, demonstrated that patients whose physician used this tool had greater knowledge of breast cancer, treatment, and treatment outcomes, had lower decisional conﬂ ict, and expressed higher satisfaction with their decision following a consultation with their physician.

Because these tools are increasingly available,²⁴ decision aids will likely become useful for a greater number of patients, physicians, and treatment options.

4.4.2. Public Disclosure of Report Cards and Clinical Decision Making

The impact of disclosure of outcome data [such as the reporting of hospital and surgeon risk- adjusted mortality rates for coronary artery bypass graft (CABG) on decision making has been controversial. Although outcome data were rarely published prior to the mid-1980s,²⁵ the ﬁ rst release of hospital risk-adjusted mortality rates in December 1990²⁶ and the ﬁ rst formal public release published in December 1992²⁷ ushered in a new era of public reporting. These performance reports, sometimes called “physician scorecards,”

have become more prevalent in recent years.^28,29 Advocates of this form of reporting believe they

provide information about quality of care that consumers, employers, and health plans can use to improve their decision making and to stimu- late quality improvement among providers.³⁰

These reports have raised concern regarding their effect on patient care and surgeon decision making. Most of the problems surgeons have with public reporting are that the risk adjustment schemes intended to “level the playing fi eld” are considered inadequate to tease out how their patients differ from others. If there is not complete confi dence in the risk adjustment strategy, then publication of procedural mortality rates may cause physicians to withhold offering a procedure to high-risk patients. To address this issue, Narins and colleagues²⁹ assessed the attitudes and experiences of cardiologists by admin- istering an anonymous questionnaire to all physicians who were included in the Percutane- ous Coronary Interventions (PCI) in New York State 1998–2000 report.³¹ The physicians were sent nine statements/questions regarding the New York report and were asked to rate their level of agreement with each statement/question. Of the 120 physicians (65% response rate) who responded, the vast majority indicated that the PCI in New York State report infl uences their clinical decision-making process. Eighty-three percent agreed or strongly agreed that “patients who might benefi t from angioplasty may not receive the procedure as a result of public reporting of physician specifi c mortality rates.” As well, 79% agreed or strongly agreed that the presence of the scorecard infl uences whether they decide to treat a critically ill patient with a high expected mortality rate. Further analyses showed that physicians performing coronary angioplasty procedures at a major university teaching hospital were signifi cantly more likely than other physicians to agree that “the publication of mortality statistics factors into their decision on whether to intervene in critically ill patients with high expected mortality rates.” The authors concluded that while the scorecards were developed to improve healthcare outcomes, they may instead adversely affect the healthcare decisions for individual patients, particularly those with a high expected mortality rate. In fact, migration of high-risk patients outside of the reporting sphere of infl uence has been found to occur. Omoigui

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and coworkers³² reviewed 9442 isolated coronary artery bypass operations performed at the Cleve- land Clinic between 1989 and 1993 to compare mortality rates for patients from New York who underwent CABG at the Cleveland Clinic with those treated in New York. Results indicated that patients from New York had a higher expected mortality and experienced higher morbidity and mortality than other patients operated on at this clinic. However, although physicians may be paying attention to the scorecards, evidence sug- gests that patients are not. In a survey of nearly 500 patients who had undergone CABG surgery during the previous year, only 20% reported awareness of their state’s CABG performance reports, and only 12% knew of this guide prior to undergoing surgery. Furthermore, less than 1%

of these patients knew the correct rating for their surgeon or hospital.³⁰

4.4.3. Medical–Legal Issues and Clinical Decision Making

Another important social factor that may infl u- ence behavior is the medicolegal climate in which surgeons practice. Fear of lawsuits appears to infl uence behavior in many specialties such as obstetrics and neurosurgery. In many states where insurance rates have soared, these practitioners have often stopped practicing. This has led to surgeon-specialists shortage in many regions. Short of stopping the practice of surgery, it is also likely that surgeons may be infl uenced by the medicolegal risk associated with certain operations in certain populations. Although the extent of this infl uence is unclear, in thoracic surgery it would be surprising if this did not infl uence care to some extent. The effect of medicolegal challenges on decision making in thoracic surgery has not been well explored but may be important given that a signifi cant percentage of cardiothoracic surgeons will face such a challenge in their career.

4.5. Summary

Surgeons may like to believe that evidence drives clinical decision making, but a host of nonclinical factors likely inﬂ uence the care we direct.

This is a possible explanation for the widespread variability in the use and types of clinical care across different regions and between countries.

While the research methodology used to understand these effects is limited, further investigation into these factors may help explain and control variability in clinical care and outcomes.

Broad areas of nonclinical infl uences include surgeon-specifi c features (attitudes about risk taking, demographics, and training), system- specifi c factors (incentives, guidelines, and scru- tiny of outcomes), and social factors (patient perspectives of nonclinical components of care, public reporting of performance, and medicolegal issues). Surgeons need to better assess and limit these nonclinical components of decision making as we aim to provide rationale, consistent, and appropriate care to our patients.

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