People diagnosed with multiple sclerosis (MS) and their neurologists must make many decisions when it comes to treating the disease. With FDA-approved disease-modifying therapies, it can be challenging to know which one to use, if any.
How do doctors and patients choose? To make an informed decision, neurologists are expected to follow clinical practice guidelines that frequently summarize the available medical evidence. Meanwhile, patients are expected to do their own research and consider lifestyle factors and personal preference, as well as doctor recommendations.
It’s clearly unwise for neurologists to follow outdated clinical guidelines; consider that when the American Academy of Neurology (AAN) published its guidelines in 2002, only four treatment options were available. A less obvious concern is when neurologists ignore current clinical guidelines and instead follow the recommendations of other neurologists they know or experts in the field, a behavior called “herding.”
Herding can be detrimental to patient care, suggests a study published in January 2017 in the journal Patient Preference and Adherence.
What is herding in medicine?
Herding is a phenomenon in which individuals follow the behavior of others rather than making a decision independently. Herding occurs in MS care when one neurologist follows the therapeutic recommendation of a colleague even when this advice is not supported by clinical guidelines.
To measure the potential of herding behavior in MS treatment, researchers in Spain conducted a study among neurologists with expertise in MS patient care. Participants answered questions regarding 20 case scenarios commonly encountered in clinical practice and completed three surveys and four experimental paradigms based on behavioral economics.
One case scenario involved a 40-year-old woman who had been stable for three years on subcutaneous interferon therapy before a minor relapse. Magnetic resonance imaging (MRI) revealed no new lesions, and the results of her neurological examination and disability scores were unchanged. The patient was advised by an MS neurologist — a colleague of her regular doctor — to switch from interferon to fingolimod, a recommendation that went against current best-practice guidelines.
The neurologists participating in the study were asked what treatment they would recommend for this patient after learning of the colleague’s suggestion. Those who decided to go with the colleague’s choice were considered to be herding.
Of the 96 neurologists in the study, herding behavior was present in 75 (78.1 percent overall). General neurologists showed greater herding behavior than MS experts — 82.8 percent versus 68.8 percent, respectively. The physicians who saw greater numbers of MS patients each per week were more likely to herd. Physician age, gender, years of practice, setting of practice, and risk preferences were not associated with herding.
When does herding harm?
If a doctor follows the erroneous or inappropriate example of another physician, he or she may not be giving a patient the best clinical care. Here is an example of “negative herding” discussed by the study authors: Residents in a hospital setting routinely follow staff recommendations; general practitioners follow specialists’ advice; and specialists commonly follow experts in the field, called “opinion leaders,” even when those experts provide erroneous recommendations.
Just because an expert has an opinion about treatment doesn’t make it the right choice for every patient. A physician needs to assess each individual’s unique case before coming to a therapeutic decision. Herding-like behavior can get in the way of that assessment, which can lead to medical error.
When might herding help?
MS treatment plans based on herding certainly may be superior to those that rely on outdated clinical guidelines. Plus, when doctors follow the example of MS-specialty neurologists on the cutting edge of research, they may learn about effective new treatments that have yet to be incorporated into general practice or clinical guidelines.
What can you do as a patient about herding behavior?
A positive working relationship with your physician is vital, marked by mutual respect and an openness to discussing concerns and treatment options. There is not much you can do about herding, but you can certainly ask questions to make sure your doctor is paying attention to your illness. Here are some suggestions:
- If my current treatment is working well, do you see any reason I should consider switching? If so, why?
- If my disease activity increases, should I consider switching treatments? What would you recommend, and why?
- What evidence is there that this treatment might be the best choice for me?
- Is your suggestion based on current clinical guidelines?
- Are there any reasons why I should avoid this treatment based on the specifics of my case?
See More Helpful Articles:
Saposnik G, Mauring J, Sempere AP, et al. Herding: a new phenomenon affecting medical decision-making in multiple sclerosis care? Lessons learned from DIScUTIR MS. Patient Prefer Adherence. 2017;11:175-180. doi: 10.2147/PPA.S124192. eCollection 2017.
Lisa Emrich is a patient advocate, accomplished speaker, author of the award-winning blog Brass and Ivory: Life with MS and RA, and founder of the Carnival of MS Bloggers. Lisa uses her experience to educate patients, raise disease awareness, encourage self-advocacy, and support patient-centered research. Lisa frequently works with non-profit organizations and has brought the patient voice to health care conferences and meetings worldwide. Follow Lisa on Facebook, Twitter, and Pinterest.