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Same patient, different advice: a study into why doctors vary
  1. T Rakow1,
  2. C Bull2
  1. 1Department of Psychology, University of Essex, UK
  2. 2The Hospital for Sick Children, Great Ormond Street, London, UK
  1. Correspondence to:
    Dr T Rakow, Dept of Psychology, University of Essex, Wivenhoe Park, Colchester CO4 3SQ, UK;


Aim: To understand why doctors differ in their recommendations in situations where there is little certainty about the long term outcomes of the possible treatment options.

Methods: A correlational design was used to examine the relation between preference for different treatment options and beliefs about likely outcomes for these options. Eighty doctors, with a mean of nine years in paediatric cardiology/surgery, attending a conference on serious congenital heart disease were studied. Main outcome measures were: ratings of the extent to which each of four treatment options were favoured; and subjective probabilities for three outcomes—death, survival with “good heart function” (New York Heart Association functional class (NYHA) I or II), and survival with “poor heart function” (NYHA III or IV)—for different treatment options over a 20 year time frame.

Results: Preference for one treatment option over another was most closely associated with the subjective estimate of the additional years with “good heart function” that it offered 10–20 years after surgery (Pearson’s r = 0.66, p < 0.001). In influencing a preference, the possibility of early death was subordinate to optimising the late outcome.

Conclusions: Doctors’ treatment preferences are consistent with selecting the option that maximises the chance of the best outcome (long term survival with good heart function). Doctors’ recommendations imply that they place more value on years of life in the child’s far future than on life-years in the immediate future.

  • decision making
  • treatment preferences
  • univentricular heart
  • subjective probability of outcomes
  • NYHA, New York Heart Association
  • TCPC, total cavopulmonary connections

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  • * Subjective estimates of the percentages in the three states were read from the graphs to the nearest 1% with the aid of a grid on a transparent film at 30 days (the left vertical axis) and then at 2.5 year intervals from 2.5 to 20 years, giving measures at nine time points. To take account of perceived operative mortality or change in functional status associated with TCPC completion, separate readings were taken before and after TCPC completion (as inferred by the presence of a vertical or near vertical line at 5 years).

  • Some caution should be exercised here, as estimates of the chance of survival beyond 20 years were not elicited. Prospects beyond 20 years are likely to correlate more strongly with long term outcomes than with medium term outcomes. If doctors take outcomes beyond 20 years into account this would then inflate the apparent value of survival between 10 and 20 years. This does not invalidate the assertion that longer term outcomes are highly weighted, but does influence the estimate of relative value.

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