helpful consequences of requiring such links to endow a patient's suffering with legitimacy. Clinging to this standard becomes a barrier to acceptance if, given the resolution of our present technology, we are unable to identify a pathophysiologic basis for illness. More generally, the reductionist model of disease restricts psychosomatic research to the pathophysiology of affective states and keeps the focus of clinical efforts on treating disease rather than people. If we can accept the patient with chronic fatigue regardless of its pathophysiologic basis, we can turn our attention to the important question of whether conceptualizing chronic fatigue as a disease is a useful h e u r i s t i c - - a s disease definitions should ultimately be j u d g e d - - f o r research, clinical practice in general, or the care of a particular patient. ~ ROBERTA. ARONOWITZ, MD, University o f Medicine a n d Dentistry o f N e w J e r s e y /
Robert Wood J o h n s o n Medical School, Camden, NJ 08103
Reference 1. Swift J. A modest proposal. In: Kermode F, Hollander J (eds). Oxford anthology of English literature, vol 1. New York: Oxford University Press, 1973.
Interpretation of Probability Terms To the E d i t o r : m In Mazur and Hickam's recent contribution, ~"Patients' Interpretation of Probability Terms," they I noted that there had not been studies of patients' perceptions of the meanings of the probability terms in the past. As a matter of fact, almost ten years ago as part of a "quality assurance program," I had sought an answer to that q u e s t i o n - - admittedly indirectly but with non-health professionals. Thus, with a sample of 80 graduate students in the University of Washington's School of Business Administration, and among 40 respondents of the 42 lay members of the Board of Trustees at our Children's Hospital, the means of the respondents were remarkably consistent with those of the health professionals. But, of far more import, the spreads among all of the groups were equally enormous. As a consequence, I suggested attempting to emulate our weather forecasters by inserting quantitative probability terms following such qualitative statements. But, unfortunately, the suggestion appeared to fall on deaf e a r s - although there is a hint that the emerging discipline of "risk communication" may be able to "convert the heathens" where I failed. When the suggestion was offered to the now retiring editor of the N e w England J o u r n a l o f Medicine to spruce up communication as he had done in the instance of abbreviations, he, too, was reluctant to bite. Better luck to Mazur and Hickam. mWILLLAMO. ROBERTSON,MD, Professor o f Pediatrics, Children's Hospital and Medical Center, and Department o£ Pediatrics, University o f Washington School o f Medicine, Seattle, WA 98195.
Reference 1. Mazur DJ, Hickam DH. Patients' interpretations of probability terms. J Gen Intern Med. 1991 ;6:273-40.
In reply: - - We thank Dr. Robertson for making us aware of his previous work. One problem with gaining understanding of the meanings of verbal terms is the large number of words that can be used to describe probabilities. Thus, none of the five terms studied by Dr. Robertson ~ was included in the list of 12 terms used in our study 2 or that used in the study of Kong et al. 3 Therefore, comparison of our results to Dr. Robertson's is difficult.
While substituting a number (such as "30% c h a n c e " ) for the verbal probability expression (such as " u n l i k e l y " ) may lead to greater understanding, as originally proposed by Dr. Robertson, 1we feel that accurate communication is possible using conventional language. Our finding that patients tend to ascribe numerical meanings in a predictable order suggests that physicians and patients will understand each other when discussing medical risk, as long as the physicians remember how patients tend to order the words. We agree with Dr. Robertson that the wide variation in laypersons' numerical probabilities associated with words makes it difficult to predict the exact number a patient ascribes to a certain medical risk. The meanings of verbal probability terms are also related to the c o n t e x t in which the respondent is asked to provide an opinion. For example, the question of what numerical probability is assigned to the verbal probability term "possible" in the statement, "It is possible that there is life on Venus," may differ from its meaning in the statement, "It is possible that you will suffer a stroke during the carotid endarterectomy that you are being asked to consent to as a therapeutic intervention." Thus, we explained to the patients in our study that we wanted to know the meanings of terms within the context of the risk of complications occurring from a surgical procedure. Patients' numerical meanings may vary in other contexts. - - DENNISJ. MAZUR,MD, PhD, and DAVIDH. HICKAM, MD, MPH, D e p a r t m e n t o f Veterans Affairs Medical Center and Oregon Health Sciences
University, Portland, OR 9 7 2 0 7 References 1. Robertson WO. Quantifying the meanings of words. JAMA. 1983;249:2631-2. 2. Mazur DJ, Hickam DH. Patients' interpretations of probability terms. J Gen Intern Med. 1991 ;6:237-40. 3. Kong A, Barnett GO, Mosteller F, Youtz C. How medical professionals evaluate expressions of probability. N Engl J Med. 1986;315:740-4.
Advance Care Directives To the Editor: - - The well-designed and well-conducted study of Brunetti et al. confirms the anecdotal experience of many patients and practitioners: knowledge does not always translate into action. ~ The authors find it paradoxical that physicians' awareness of advance care directives (ACDs) (97.2%) and belief in their utility ( 8 6 - 9 3 % ) translate into only a one-in-five chance that extraordinary care issues will be discussed. It is arguable that these data indicate "a failure in p h y s i c i a n - p a t i e n t communication." Practitioners and patients must communicate about many health care issues and preferences. Advance care directives are a single, albeit important issue; to advocate that they be addressed all or most of the time in ambulatory care begs the question regarding "patient preferences." Paternalism may be to assert that physicians routinely raise the issue in a nonemergent or nonimminent setting. The issue of relevancy and appropriateness of ACDs requires examination as well. Although oncologists responded to the study questionnaire at a rate of 100%, only about 75% of other physicians responded. Could it be that physicians who regularly treat patients faced with death and dying find ACDs more relevant and appropriate than do other physicians? Further, only 13.5% of physicians executed ACDs for themselves. Physicians are no different from patients in this regard; they address relevant or imminent issues more readily than theoretical contingencies. The literature on ACDs suffers
JOURNALOFGENERALINTERNALMEDICINE, Volume 7 (January/February), i992
from a systematic bias. Extraordinary instances of prolonged life support are used to infer a standard of practice for the general population. What we need to know before patients and physicians spend their health discussing death, is the probability that such discussion is relevant for an individual. What patient profiles mandate this discussion? z Besides patients with terminal cancer, what other non-hospitalized patients w o u l d benefit from ACDs? Cardiopulmonary resuscitation and intensive care are expensive and, at times, undignified, but the execution of ACDs by the majority of the population will not be inexpensive. What is the c o s t - b e n e f i t ratio for ACDs as a public policy? Any benefit of ACDs w o u l d be negated if previously stated preferences are regularly reversed whenever death is imminent. What is the effect of "framing" on the expression of patient preferences? 3 What are the conditional and temporal limitations to any previously expressed preference? It may be more ethical, more economical, and more relevant for patients and physicians to negotiate the intensity and duration of medical care on a day-to-day basis than by prior directive. Perhaps ACDs have an appropriate, but not ecumenical, role in ambulatory care medicine.--DOMINIC J. B ~ , MD,
Veterans Affairs Regional and Medical O~ce Center, White River Junction, VT05009-0001 References 1. Brunetti LL, Carperos SD, Westlund RE. Physicians' attitudes towards living wills and cardiopulmonary resuscitation. J Gen Intern Med. 1991;6:323-9. 2. MossAH. Informing the patient about cardiopulmonaryresuscitation: when the risks outweigh the benefits. J Gen Intern Med. 1989;4:349-55. 3- TverskyA, KahnemanD. The framingofdecisionsandthepsychology of choice. Science. 1981 ;211:453-8.
In reply:--We agree with Dr. Balestra that, within the time limits of an office visit, patients and physicians must communicate about many health care matters. Although we scored responses on a scale from 1 to 5, we were not implying that a score of " 5 " was expected. Indeed, it is unrealistic to expect that physicians address cardiopulmonary resuscitation (CPR) wishes during each office visit or to the exclusion of more emergent matters. However, we believe that a patient's wishes regarding extraordinary care are more than merely a "theoretical contingency." After all, Karen Ann Quinlin and Nancy Cruzan were young w o m e n in good health before meeting their tragic fates. The probability that a young, healthy person will suffer a catastrophic illness, such as severe trauma, is small; however, in this age group, it is the leading cause of death. Because primary care physicians provide longitudinal care, they are in the best position to question patients (of whatever age), in a nonemergent setting, about their health care p r e f e r e n c e s - in much the same way as other " p r e v e n t i v e " medical issues are discussed. Additional motivation for documenting patient wishes comes from the Cruzan case. In Cruzan, the Supreme Court ruled that a competent person's decision to forgo extraordinary care should be honored; however, the Court did not guarantee that the unexpressed wishes of an incompetent person should bear equal weight and be followed. The clear implication of Cruzan is, if a person has chosen not to receive extraordinary care, then these wishes must be made known. Execution of advance care directives (ACDs) should not be expensive, as they are readily available free, or at nominal cost from state medical societies, bar associations, and special
interest groups. Unlike last wills and testaments, an attorney is not needed to execute one! Relative to the cost of unwanted medical care, the cost/benefit ratio of ACD use, although unknown, should be very low. The benefit of ACDs could be negated if preferences are consistently reversed. However, there are no data to suggest that such reversals occur with any great regularity. We believe it is far more paternalistic to avoid initiating discussion about CPR preferences just because you believe the patient's wishes will change. If physicians communicate with and educate their patients about the benefits of ACDs, perhaps the old saying from medical school of "see one, do one, teach o n e " will translate into a greater chance that extraordinary care issues will be readily discussed by both doctors and their p a t i e n t s . - Louis L. BRLrNETrl, MD, JD, Carolinas Medical Center, Charlotte, NC 28232-2861; and STEPHANIE CARPEROS, MD, The Davidson Clinic, Davidson, NC 28036
Ultrasonography for Abdominal Aortic Aneurysm To the Editors:-- In their recent review, ~ Reuler and Kumar cite data from an analysis by Quill et al. 2 to support their conclusion that ultrasound screening for abdominal aortic aneurysm (AAA) is not cost-effective. This conclusion can be challenged on several grounds. The cost per life saved for one-time (or every-ten-year) ultrasound screening of $78,000 compares favorably with the costs per life saved of many accepted medical practices and was considered to be cost-effective by Quill et al. in the original article. The $78,000 consisted almost entirely of the cost of treatment, which in this model included operation on all AAAsdetected, even those less than 4 cm. A screening program that employed a more selective use of surgery, as described elsewhere in the review, would considerably reduce the cost per life saved. Reducing the prevalence fourfold (from 10% to 2.5%) raised the cost per life saved by less than 40%. The figures of $150,000 per diagnosis and $600,000 per life saved quoted in the review refer to annual retesting, w h i c h is clearly too short an interval and, to my knowledge, has never been recommended. Reuler and Kumar also consider abdominal palpation to screen for AAA to be unsupportable because of low positive predictive value and sensitivity. The only consequence of a positive predictive value of 22% is that four confirmatory ultrasound tests will be done per diagnosis, still a very high yield. The 50% sensitivity of abdominal palpation makes it less desirable than ultrasonography for screening since fewer AAAs are detected, but the costs per AAA detected are similar (about $1,500, assuming 10% prevalence, $150 for ultrasonography, and $ 25 for abdominal palpation) and the largest, most dangerous AAAsare preferentially detected, 3 so it is better than nothing. The authors have provided internists with much useful information about abdominal aortic aneurysms. It would be unfortunate if, in the process, the internist's crucial role as diagnostician were d i m i n i s h e d . - FRANKA. LEDERLE,MD, D# vision of General Internal Medicine, Department of Medicine, Minneapolis VA Medical Center, Minneapolis, MN 55417 References 1. Reuler JB, Kumar KL. Abdominal aortic aneurysm. J Gen Intern Med. 1991 ;6:360-6. 2. Quill DS, Colgan MP, Sumner DS. Ultrasonic screening for the