More recently, Dr. Miller said, he was again approached by administration and pharmacy on substituting Botox with a less costly option, and he talked to them about how that process could take shape. He said he is open to using an alternative such as Xeomin for patients new to chemodenervation but would study this change to make sure it is as effective as Botox. He would not expect patients already receiving Botox to change, though, to which the administration and pharmacy agreed, he said.
Explore This Issue
March 2025While each situation is different, Dr. Miller said, “I try to understand where the other side is coming from and then work toward a resolution where all of us are happy.”
He said he would be open, perhaps, to using another product, but only after it was studied, and never for patients who had already had their treatment process started using the brand-name Botox.
When to take a stand is a complicated question with no simple answer, depending on where you are in your career, your experience, the issue you’re fighting for, and other factors. But Dr. Miller was appreciative of the efforts of Dr. Clark, who he said is an “incredibly passionate physician wanting to always do right for his patients.”
Dr. Clark said that sometimes an administrative decision requires action. Botox has stayed on the outpatient formulary, where it is most essential, he said, and the key was presenting clear evidence that the treatment is best for patient care.
“You can’t just sit there and throw your hands up and say, ‘They can’t do that,’” he said. “We have to advocate for our patients, including making an impassioned argument for keeping it on the formulary.”
Some of the most common conflicts facing physicians might not involve a dynamic between people, but may happen when interpreting test data and patient-reported symptoms that seem to be at odds with each other, said Jennifer Shin, MD, associate dean for faculty affairs at Harvard Medical School in Boston.
This can happen, for instance, when a patient feels like their sinuses have an ongoing infection but a CT suggests otherwise.
“Even if the patient and clinicians are perfectly aligned, that mismatch between the subjective and objective results can lead to a conflicting directive, for both clinical care and research,” Dr. Shin said. “It actually is a real conundrum for clinicians, because it could leave us treating for objective tests, and less focused on whether a patient says they still feel symptomatic.”
Much medical literature shows that subjective and objective outcomes are not in sync, she said, at least with how patient symptoms are used, even with well-known, established, validated instruments.
“When funding is allocated for research projects, you typically pick a primary outcome, and that primary outcome can be either subjective or objective, so if they are not aligned, it also creates a conundrum in study designs,” she said. Practitioners might have simply defaulted to the objective test in the past, she said. But we are now in an era in which the government-sponsored Patient-Centered Outcomes Research Institute (PCORI) and Agency for Healthcare Research and Quality (AHRQ) emphasize patient-centered assessments and their importance beyond diagnostic test results, and researchers are increasingly examining the objective tests to determine whether they should be revamped to better reflect what patients experience.
Research also is shedding light on how the psychological status of a patient can affect how well objective testing lines up with patient-reported symptoms.
In a study on which Dr. Shin served as the senior author, researchers found that results on the Sino-Nasal Outcome Test-22 (SNOT-22) were in more concordance with CT imaging for patients with better psychological status than in those with worse psychological status, for whom SNOT-22 scores were non-discriminatory for CT findings (Otolaryngol Head Neck Surg. doi: 10.1177/0194599820926129).
In another study, Dr. Shin’s group found a similar theme within hearing loss and developed a novel way to overcome the discordance. Subjective Inner EAR scores were associated with objective audiometry results in patients with better mental status but not in those with worse mental status, when a static form of the Inner EAR test was used. When an adaptive form of the Inner EAR test was used, however—in which previous responses determine which subsequent questions are posed—those subjective findings retained their association with audiometry, even in those with worse mental status (Otolaryngol Head Neck Surg. doi: 10.1001/jamaoto.2024.0898).
“People often try to figure out how to gain more information by asking more questions,” she said. “But what we’ve realized is that you can actually ask fewer questions—you just have to ask the right questions under the right circumstances to the right patient at the right time. An adaptive mechanism can really help.”
Thomas R. Collins is a freelance medical writer based in Florida.
Leave a Reply