Gafni A, Charles C, Whelan T
Department of Clinical Epidemiology and Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
Soc Sci Med. 1998 Aug;47(3):347-54. doi: 10.1016/s0277-9536(98)00091-4.
Assuming a goal of arriving at a treatment decision which is based on the physician's knowledge and the patient's preferences, we discuss the feasibility of implementing two treatment decision-making models: (1) the physician as a perfect agent for the patient, and (2) the informed treatment decision-making models. Both models fall under the rubric of agency models, however, the requirements from the physician and the patient are different. An important distinction between the two models is that in the former the patient delegates authority to her doctor to make medical decisions and thus the challenge is to encourage the physician to find out the patient's preferences. In the latter, the patient retains the authority to make medical decisions and the physician role is that of information transfer. The challenge here is to encourage the physician to transfer the knowledge in a clear and nonbiased way. We argue that the choice of model depends among other things on the ease of implementation (e.g., is it simpler to transfer patient's preferences to doctors or to transfer technical knowledge to patients?). Also the choice of treatment decision-making model is likely to have an impact on the type of incentives or regulations (i.e., contracts) needed to promote the chosen model. We show that in theory both models result in the same outcome. We argue that the approach of transferring information to the patient is easier (but not easy) and, hence, more feasible than transferring each patient's preferences to the physician in each medical encounter. We also argue that because better "technology" exists to transfer medical information to patients and time costs are involved in both tasks (i.e. transferring preferences or information), it is more feasible to design contracts to motivate physicians to transfer information to patients than to design contracts to motivate physicians to find out their patients' utility functions. We illustrate our arguments using a clinical example of the choice of adjuvant chemotherapy versus no adjuvant chemotherapy for women with early stage breast cancer. We also discuss issues relating to the current realities of clinical practice and their potential implications for the way that economists model physician-patient clinical encounters.
假设目标是做出基于医生知识和患者偏好的治疗决策，我们讨论实施两种治疗决策模型的可行性：（1）医生作为患者的完美代理人；（2）知情治疗决策模型。这两种模型都属于代理模型范畴，然而，对医生和患者的要求不同。这两种模型的一个重要区别在于，在前者中患者将做出医疗决策的权力委托给医生，因此挑战在于鼓励医生了解患者的偏好。在后者中，患者保留做出医疗决策的权力，医生的角色是信息传递。这里的挑战在于鼓励医生以清晰且无偏见的方式传递知识。我们认为，模型的选择除其他因素外，取决于实施的难易程度（例如，将患者偏好传递给医生还是将技术知识传递给患者更简单？）。此外，治疗决策模型的选择可能会对促进所选模型所需的激励措施或监管（即合同）类型产生影响。我们表明理论上这两种模型会产生相同的结果。我们认为将信息传递给患者的方法更容易（但并非易事），因此比在每次医疗接触中将每个患者的偏好传递给医生更可行。我们还认为，由于存在更好的“技术”将医疗信息传递给患者，并且在这两项任务（即传递偏好或信息）中都涉及时间成本，设计合同激励医生向患者传递信息比设计合同激励医生了解患者的效用函数更可行。我们使用早期乳腺癌女性辅助化疗与不进行辅助化疗选择的临床实例来说明我们的论点。我们还讨论了与临床实践当前现实相关的问题及其对经济学家构建医患临床接触模型方式的潜在影响。
