Provider Recommendations in the Face of Scientific Uncertainty: An Analysis of Audio-Recorded Discussions about Vitamin D

Abstract

BACKGROUND:Little is known about how providers communicate recommendations when scientific uncertainty exists. OBJECTIVES: To compare provider recommendations to those in the scientific literature, with a focus on whether uncertainty was communicated. DESIGN: Qualitative (inductive systematic content analysis) and quantitative analysis of previously collected audio-recorded provider-patient office visits. PARTICIPANTS: Sixty-one providers and a socioeconomically diverse convenience sample of 603 of their patients from outpatient community-and academicbased primary care, integrative medicine, and complementary and alternative medicine provider offices in Southern California. MAIN MEASURES:Comparison of provider informationgiving about vitamin D to professional guidelines and scientific information for which conflicting recommendations or insufficient scientific evidence exists; certainty with which information was conveyed. RESULTS: Ninety-two (15.3 %) of 603 visit discussions touched upon issues related to vitamin D testing, management and benefits. Vitamin D deficiency screening was discussed with 23 (25 %) patients, the definition of vitamin D deficiency with 21 (22.8 %), the optimal range for vitamin D levels with 26 (28.3 %), vitamin D supplementation dosing with 50 (54.3 %), and benefits of supplementation with 46 (50 %). For each of the professional guidelines/scientific information examined, providers conveyed information that deviated from professional guidelines and the existing scientific evidence. Of 166 statements made about vitamin D in this study, providers conveyed 160 (96.4 %) with certainty, without mention of any equivocal or contradictory evidence in the scientific literature. No uncertainty was mentioned when vitamin D dosing was discussed, even when recommended dosing was higher than guideline recommendations. CONCLUSIONS AND RELEVANCE: Providers convey the vast majority of information and recommendations about vitamin D with certainty, even though the scientific literature contains inconsistent recommendations and declarations of inadequate evidence. Not communicating uncertainty blurs the contrast between evidence-based recommendations and those without evidence. Providers should explore best practices for involving patients in decision-making by acknowledging the uncertainty behind their recommendations. INTRODUCTIONMedical care is full of uncertainty. Uncertainty is inherent in most diagnostic and treatment decisions.1,2 Decision-making is complicated by equivocal, insufficient or nonexistent scientific evidence, and by differences in provider or patient interpretations of the evidence. Medical communication guidelines suggest disclosing uncertainty to patients.3,4 Yet providers typically fail to convey uncertainty, 5 and the scientific literature contains little information about provider recommendations in the context of uncertainty.Vitamin D supplementation is a good topic for investigating provider-patient communication around scientific uncertainty, because 26-56 % of Americans tak...

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“…This source was associated with better knowledge regarding VitD. Previous studies have shown that physicians are a major source of VitD-related information [19,23,28,31,35]. This highlights the important role played by physicians (trusted source of information) in the education of their patients [20,23,25,26].…”

“…Such information would be of interest for practitioners and public health institutions to improve the communication regarding VitD. Previous studies performed in several countries (mostly targeting specific groups) showed that VitD-related knowledge was limited [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36]. To our knowledge, no study was performed in a large European sample from the general population and few linked VitD-related knowledge to various individual characteristics (including measured VitD status).…”

Clinical Management of Low Vitamin D: A Scoping Review of Physician Practices

“…The topic of vitamin D came up in more than 15% of patient encounters in the study of Southern California, U.S. physicians [51]. In spite of a great deal of uncertainty regarding vitamin D information and guidelines, physicians conveyed over 95% of vitamin D-related statements with certainty [51].…”

“…The topic of vitamin D came up in more than 15% of patient encounters in the study of Southern California, U.S. physicians [51]. In spite of a great deal of uncertainty regarding vitamin D information and guidelines, physicians conveyed over 95% of vitamin D-related statements with certainty [51]. For example, some patients were told that vitamin D screening was routinely recommended in spite of insufficient evidence to support screening [51].…”

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“…Additionally, a small study by Tarn et al . suggested that the uncertainty inherent in the varying vitamin D guidelines does not get conveyed to patients, resulting in patients getting unnecessarily screened and treated for vitamin D deficiency [105]. While not representative of all clinical practices, it underlines the importance of providing consistent vitamin D guidelines to minimize variations in patient care.…”