Personal view: 'don't ask, don't tell'--the undesirable consequences of incidental test results in gastroenterology

Secondary variants--in defense of a more fitting term in the incidental findings debate

New genetic technologies are capable of returning far more information than the single answer to the single question posed when conducting a given genetic test. Genetics contexts consequently stand on the brink of an explosion of what have traditionally been called 'incidental findings'. However, the continued use of this term is controversial. Various replacements for 'incidental findings' have been attempted, but none with widespread success. Agreement on terminology and definitions is vital so that the legal and ethical debate around incidental findings can proceed. We highlight the difficulties raised by the various terms currently used as alternatives, and end by defending our choice for the term 'secondary variants'.

Understanding medication compliance and persistence from an economics perspective

OBJECTIVES

An increased understanding of the reasons for noncompliance and lack of persistence with prescribed medication is an important step to improve treatment effectiveness, and thus patient health. Explanations have been attempted from epidemiological, sociological, and psychological perspectives. Economic models (utility maximization, time preferences, health capital, bilateral bargaining, stated preference, and prospect theory) may contribute to the understanding of medication-taking behavior.

METHODS

Economic models are applied to medication noncompliance. Traditional consumer choice models under a budget constraint do apply to medication-taking behavior in that increased prices cause decreased utilization. Nevertheless, empiric evidence suggests that budget constraints are not the only factor affecting consumer choice around medicines. Examination of time preference models suggests that the intuitive association between time preference and medication compliance has not been investigated extensively, and has not been proven empirically. The health capital model has theoretical relevance, but has not been applied to compliance. Bilateral bargaining may present an alternative model to concordance of the patient-prescriber relationship, taking account of game-playing by either party. Nevertheless, there is limited empiric evidence to test its usefulness. Stated preference methods have been applied most extensively to medicines use.

RESULTS

Evidence suggests that patients' preferences are consistently affected by side effects, and that preferences change over time, with age and experience. Prospect theory attempts to explain how new information changes risk perceptions and associated behavior but has not been applied empirically to medication use.

CONCLUSIONS

Economic models of behavior may contribute to the understanding of medication use, but more empiric work is needed to assess their applicability.

Personal view: passing the buck and taking a free ride -- a game-theoretical approach to evasive management strategies in gastroenterology

BACKGROUND

'Free-riding' physicians enjoy the status, prestige and income of their profession without fully contributing to its overall mission. By shifting the costs of potential medical complications and difficult patient encounters to other physicians, they reap the benefits of their profession without carrying its full weight.

AIM

To describe this phenomenon in terms of decision analysis and characterize the parameters affecting its occurrence.

METHODS

The interaction between two physicians is modeled as a non-zero-sum game. Two strategies of either contributing to patient management or taking a free ride are available to both physicians. The four possible outcomes are arranged in a two-by-two game matrix.

RESULTS

Physicians practice medicine because their personal benefit exceeds their cost. High cost to the physician results in a high probability of taking a free ride and copping out from potentially risky management. Increasing the benefit decreases the probability of free riding. As the number of possible encounters with other physicians increases, the probability of free riding increases and the probability for effective management by each individual physician decreases.

CONCLUSION

If individual gastroenterologists felt less threatened by administrative repercussions and medico-legal consequences of untoward events, each one of them would contribute more to effective patient management.

Personal view: victim blaming as management strategy for the gastroenterologist--a game theoretical approach

BACKGROUND

A multitude of digestive diseases elude simple management strategies. Rather than admit failure of disease management, a gastroenterologist could resort to blaming patients for their own medical conditions. Blaming the patient constitutes an easy exit strategy for otherwise unsolvable disease conditions.

AIM

To shed light on the problem of patient blaming in gastroenterology and provide means for its resolution.

METHODS

The interaction between physician and patient can be formulated in terms of a non-zero-sum game between two adversaries. The outcomes associated with two behavioural strategies available to both adversaries are arranged in a two-by-two game matrix.

RESULTS

Blaming the patient is characterized by the general game pattern of the 'prisoner's dilemma'. If the physician-patient interaction is restricted to one single event, patient blaming represents the management strategy of choice with the highest expected payoff under all foreseeable circumstances. If there is a high probability for repeated physician-patient interactions, however, a physician admitting and a patient accepting the limits of medical performance yield a dominant strategy.

CONCLUSION

Only for single physician-patient encounters does a non-cooperative strategy of blaming one's adversary for a poor medical outcome yield the highest expected outcome. In the long run, the strategy of shifting blame becomes unproductive for both sides alike.