A fundamental skill that physicians rely on is calculating risk/benefit analyses when we advise patients. My use of the word ‘calculating’ is a misnomer as there is no reliable scientific method to quantify risk and benefit. Indeed, different physicians might ‘calculate’ such an analysis differently. Similarly, different patients in the same medical circumstances might gauge the potential medical benefit differently. This is not hard science.
Some folks might feel that a 5% risk of a major complication
is acceptable, while others would balk at this statistic. And on the benefit side, is it worth taking a
medication that has some risk with the hope that it might shave 1 day off of a
7 day illness?
Despite that risk/benefit analyses are not easily quantified,
physicians and patients must enter into a dialogue on this issue when a
treatment or a test is being proposed. The
participants have to do their best to tease through the issues.
If a 25-year-old athlete develops acute appendicitis, a
risk/benefit analysis likely favors surgery.
If an 80-year-old individual develops acute appendicitis,
but also suffers from severe emphysema and heart disease, a risk/benefit
analysis might favor a conservative approach with antibiotics.
And, as every doctor knows, some patients analyze the
risk/benefit balance differently than do their doctors.
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Medicine is an art.
Can’t doctors simply look up the risks and benefits of medical treatments in medical journals or other sources? It’s not as easy as it sounds. When physicians research a particular treatment with regard to risk and efficacy, often the patients in a research study are different from the patient sitting in the office. So, doctors must be cautious before extrapolating published research conclusions to real world patients. Unlike my own patients, research participants are tightly screened. Many candidates for the research trial were disqualified from the study for a variety of reasons. So, for example, if a high quality published study concludes that a new medication decreases the risk of a heart attack by 10%, this applies only to the type of patients that were admitted into the study. It is understandable, however, that lay person who reads about this study might erroneously assume that he and everyone else should be on this medicine. Similarly, a study that points out adverse reactions and side-effects of a treatment does not mean that a random patient outside of the study would face this outcome. I encourage all who read about medical developments in the lay press to view the material through a skeptical lens.
Do your best to understand the respective risks and benefits
of the reasonable diagnostic and treatment options for your condition. It is your doctor’s responsibility to help
you to navigate through this. But this
is not a mathematical calculation where every doctor would reach the same point. If you present the same medical patient to 10
different doctors, don’t expect consensus.
Are you familiar with the adage, medicine is an art, not a science?
Good points.
ReplyDeleteIf I could marry comments that relate to 2 of your recent columns, this one and the one on pharma. Pharmaceutical companies have spent a great deal of money developing their drug and want to sell their med. Sometimes they oversell and are in cahoots with the medical establishment. For example, say drug X reduces people from being hospitalized for Heart Failure from 10 per year to 8 per year. This is a relative risk reduction of 20% which sounds pretty good. But the absolute risk reduction is only 2 per year which means you have to treat 50 to benefit one person. Somehow these modest benefits often make it into society guidelines and all the specialists start doing it even though it costs a lot. Can you see how this might add to health care costs with marginal benefits?
DeleteElliot Davidson, MD