Physician views regarding the benefits and burdens of prenatal surgery for myelomeningocele.

OBJECTIVE: Examine how pediatric and obstetrical subspecialists view benefits and burdens of prenatal myelomeningocele (MMC) closure. STUDY DESIGN: Mail survey of 1200 neonatologists, pediatric surgeons and maternal-fetal medicine specialists (MFMs). RESULTS: Of 1176 eligible physicians, 670 (57%) responded. Most respondents disagreed (68%, 11% strongly) that open fetal surgery places an unacceptable burden on women and their families. Most agreed (65%, 10% strongly) that denying the benefits of open maternal-fetal surgery is unfair to the future child. Most (94%) would recommend prenatal fetoscopic over open or postnatal MMC closure for a hypothetical fetoscopic technique that had similar shunt rates (40%) but decreased maternal morbidity. When the hypothetical shunt rate for fetoscopy was increased to 60%, physicians were split (49% fetoscopy versus 45% open). Views about burdens and fairness correlated with the likelihood of recommending postnatal or fetoscopic over open closure. CONCLUSION: Individual and specialty-specific values may influence recommendations about prenatal surgery.

Primary care physicians' and psychiatrists' approaches to treating mild depression.

OBJECTIVE: To measure how primary care physicians (PCPs) and psychiatrists treat mild depression. METHOD: We surveyed a national sample of US PCPs and psychiatrists using a vignette of a 52-year-old man with depressive symptoms not meeting Major Depressive Episode criteria. Physicians were asked how likely they were to recommend an antidepressant counseling, combined medication, and counseling or to make a psychiatric referral. RESULTS: Response rate was 896/1427 PCPs and 312/487 for psychiatrists. Compared with PCPs, psychiatrists were more likely to recommend an antidepressant (70% vs. 56%), counseling (86% vs. 54%), or the combination of medication and counseling (61% vs. 30%). More psychiatrists (44%) than PCPs (15%) were 'very likely' to promote psychiatric referral. PCPs who frequently attended religious services were less likely (than infrequent attenders) to refer the patient to a psychiatrist (12% vs. 18%); and more likely to recommend increased involvement in meaningful relationships/activities (50% vs. 41%) and religious community (33% vs. 17%). CONCLUSION: Psychiatrists treat mild depression more aggressively than PCPs. Both are inclined to use antidepressants for patients with mild depression.

Factors influencing physicians' advice about female sterilization in USA: a national survey.

BACKGROUND: Tubal ligation can be a controversial method of birth control, depending on the patient's circumstances and the physician's beliefs. METHODS: In a national survey of 1800 US obstetrician-gynecologist (Ob/Gyn) physicians, we examined how patients' and physicians' characteristics influence Ob/Gyns' advice about, and provision of, tubal ligation. Physicians were presented with a vignette in which a patient requests tubal ligation. The patient's age, gravida/parity and her husband's agreement/disagreement were varied in a factorial experiment. Criterion variables were whether physicians would discourage tubal ligation, and whether physicians would provide the surgery. RESULTS: The response rate was 66% (1154/1760). Most Ob/Gyns (98%) would help the patient to obtain tubal ligation, although 9-70% would attempt to dissuade her, depending on her characteristics. Forty-five percent of physicians would discourage a G2P1 (gravida/parity) woman, while 29% would discourage a G4P3 woman. Most physicians (59%) would discourage a 26-year-old whose husband disagreed, while 32% would discourage a 26-year-old whose husband agreed. For a 36-year-old patient, 47% would discourage her if her husband disagreed, while only 10% would discourage her if her husband agreed. Physicians' sex had no significant effect on advice about tubal ligation. CONCLUSIONS: Regarding patients who seek surgical sterilization, physicians' advice varies based on patient age, parity and spousal agreement but almost all Ob/Gyns are willing to provide or help patients obtain surgical sterilization if asked. An important limitation of the study is that a brief vignette, while useful for statistical analysis, is a rough approximation of an actual clinical encounter.

Autonomy, religion and clinical decisions: findings from a national physician survey.

BACKGROUND: Patient autonomy has been promoted as the most important principle to guide difficult clinical decisions. To examine whether practising physicians indeed value patient autonomy above other considerations, physicians were asked to weight patient autonomy against three other criteria that often influence doctors' decisions. Associations between physicians' religious characteristics and their weighting of the criteria were also examined. METHODS: Mailed survey in 2007 of a stratified random sample of 1000 US primary care physicians, selected from the American Medical Association masterfile. Physicians were asked how much weight should be given to the following: (1) the patient's expressed wishes and values, (2) the physician's own judgment about what is in the patient's best interest, (3) standards and recommendations from professional medical bodies and (4) moral guidelines from religious traditions. RESULTS: Response rate 51% (446/879). Half of physicians (55%) gave the patient's expressed wishes and values "the highest possible weight". In comparative analysis, 40% gave patient wishes more weight than the other three factors, and 13% ranked patient wishes behind some other factor. Religious doctors tended to give less weight to the patient's expressed wishes. For example, 47% of doctors with high intrinsic religious motivation gave patient wishes the "highest possible weight", versus 67% of those with low (OR 0.5; 95% CI 0.3 to 0.8). CONCLUSIONS: Doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians' decisions as much as is often recommended in the ethics literature.