Sunday, June 16, 2019

Medical Risks and Benefits - Shades of Gray

Readers know how strongly I feel that my profession is suffering from the twin chronic diseases of Overdiagnosis and Overtreatment.  Here's a primer on how physicians make medical recommendations to our patients.

Take a look at this grid I prepared, which is worth a full year of medical school.

                                    Low Benefit                   High Benefit

Low Risk                                                           Medical Sweet Spot!


High Risk                DANGER ZONE!

When we physicians are contemplating a treatment, or are weighing one treatment against another, we are aiming for the Medical  Sweet Spot highlighted in blue above.  We want low risk and high reward for our patients.   Would we ever consider a treatment within the DANGER ZONE?  We would if the patient’s medical circumstance were dire and there were no superior options.  For example, if a patient was under a serious threat of a severe outcome, we might consider a treatment with considerable risk that had limited evidence of efficacy.  Of course, it may be that an informed patient might decline the treatment. 

There are times when the Danger Zone is reasonable.

Obviously, medicine is a murky discipline and most treatments do not fall neatly into one of the 4 quadrants of this grid.  Moreover, medical experts often disagree to the extent that a treatment is safe or effective.  In other words, different physicians may place the same treatment in different regions of the grid.  This is one reason why pursuing a second opinion can become more bewildering than clarifying.   Just because a second opinion is different from the original, doesn’t make it right.  To further confuse you, two differing medical opinions can both be right!

How does an average patient make sense out of this morass?  By asking the right questions.
  • What are my reasonable treatment options?
  • What is the scientific evidence supporting each of these options?
  • What is the scientific evidence of the risks?
  • Does my personal medical situation favor one option over another?  (For example, if a medical option’s risk is to suppress the immune system, and you already have a diminished immune system, then this option may not be suitable for you.)
  • How will I be monitored for adverse drug reactions? 
  • Is no treatment an option?  Where would this choice fall on 'grid'?
In my view, the 'no treatment' option should be considered much more often.  Why do so many patients and physicians move this option ‘off the grid’?

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