Willingness to Treat with Therapies of Unknown Effectiveness in Severe COVID-19: A Survey of Intensivist Physicians

Abstract

Rationale: Little is known about how physicians develop their beliefs about new treatments or update their beliefs in the face of new clinical evidence. These issues are particularly salient in the context of the coronavirus disease (COVID-19) pandemic, which created rapid demand for novel therapies in the absence of robust evidence. Objectives: To identify psychological traits associated with physicians' willingness to treat with unproven therapies and willingness to update their treatment preferences in the setting of new evidence in the context of COVID-19. Methods: We administered a longitudinal e-mail survey to United States physicians board certified in intensive care medicine in April and May 2020 (phase one) and October and November 2020 (phase two). We assessed five psychological traits potentially related to evidence uptake: need for cognition, evidence skepticism, need for closure, risk tolerance, and research engagement. We then examined the relationship between these traits and physician preferences for pharmacological treatment for a hypothetical patient with severe COVID-19 pneumonia. Results: There were 592 responses to the phase one survey, conducted prior to publication of trial data. At this time physicians were most willing to treat with macrolide antibiotics (50.5%), followed by antimalaria agents (36.1%), corticosteroids (24.5%), antiretroviral agents (22.6%), and angiotensin inhibitors (4.4%). Greater evidence skepticism (relative risk [RR], 1.40; 95% confidence interval [CI], 1.30-1.52; P< 0.001), greater need for closure (RR, 1.19; 95% CI, 1.06-1.34; P = 0.003), and greater risk tolerance (RR, 1.17; 95% CI, 1.08-1.26; P< 0.001) were associated with an increased willingness to treat, whereas greater need for cognition (RR, 0.85; 95% CI, 0.75-0.96, P = 0.010) and greater research engagement (RR, 0.91; 95% CI, 0.88-0.95; P< 0.0001) were associated with decreased willingness to treat. In phase two, most physicians updated their beliefs after publication of trial data about antimalarial agents and corticosteroids. Physicians with greater evidence skepticism were more likely to persist in their beliefs. Conclusions: Psychological traits associated with clinical decisions in the setting of uncertain evidence may provide insight into strategies to better align clinical practice with published evidence.