Risks vs. Benefits: Get the Evidence or Fire Your Doctor

Gone are the days where you should believe what your doctor tells you simply because he or she is a doctor. Medicine can be complicated, and it changes all the time: new drugs, new resistant bugs, and new scientific studies that teach us that sometimes what we once thought was good is in fact killing people. Your job as an informed consumer of healthcare is to make sure that the benefits outweigh the risks. The stakes are too high for you to assume that your doctor knows this.

We love talking about benefits -- that's the part of the commercial with smiling lovers and chirping birds. But talking about risks is scary, so we avoid it or mention them really fast when the credits are rolling. When is the last time YOU asked about the risks of a treatment or a test?

Case 1: The doctor says: "You should have a colonoscopy." How can you decide if this makes sense for you if she doesn't also tell you that there is a 1 in 14,000 chance you will die from complications of the colonoscopy? This doesn't mean you shouldn't do it. It means there had better be a greater than 1 in 14,000 chance that it will save your life or make you healthier. (And your doctor should tell you that for colon cancer screening, the benefits indeed outweigh the risks for adults between 50 and 75 years old.)

Case 2: "There's a spot on your chest x-ray. It's probably nothing, but let's get a CT scan to make sure." Wow, what a caring doctor. What will you say to him? That's right, you should ask: "What are the benefits and risks?" If he explains them, including the fact that repeated CT scans increase your risk for cancer -- great. If she says, "I don't know, but let's find out" -- great. If he just wants you to go ahead with the treatment based only on his experience, fire him.

For doctors, it's quite difficult to find out the actual risks and benefits of the tests and treatments we recommend. You might expect that there is a regularly updated database of the top 100 treatments and invasive tests, which quantifies the risks and benefits for each of them. It doesn't exist! Most of the data needed to create such a database does exist, but it's scattered across many research articles and textbooks. I'm willing to bet that if more of you demand this information from your doctors, that database will soon exist. And I know it will help me practice better medicine.

Demand the facts and make informed decisions. Your life depends on it.

Comments

[DanZ]

(continued)

I recall how many of our fellow physicians struggled with basic statistical concepts during undergrad and the lack of question on the MCAT regarding statistics. The director of family medicine at my medical school thought I had done a poor analysis of the literature when I suggested not all post-menopausal women should be on HRT. At my medical school there was about 4 hrs of education on statistics which equated to memorisation of Bayes Theorem without the need to understand it. Little, if any, of the USMLE tests emphasised the skill set to think critically about diagnostic/screening tests. The only exception is/was the Preventive Med. Board Exam, a exam that is taken by very small percentage of physicians.

Thinking back on the lack of training/emphasis during the medical education curriculum, I have come to accept that the "average" physician does not have sufficient understanding to clearly present options to patients. Furthermore, a more difficult and specialized skillset is the ability to participate in shared decision making...

So, in the end, we did not "fire" the obstetrician as I figured it may take many trials to find a physician with these skills. I noticed that at our medical facility, if you have questions regarding these test, you can request to discuss this with a genetic screening expert who I assume has the needed skills. I do agree that these skills sets are critical and hope this becomes a more integral part of physician training.

[Roni Zeiger - Huffpost Blogger]

DanZ, what you say about gaps in medical education is spot on. Curricula in medical schools and residencies are changing, but slowly. The mismatch between what was tested when I took MCAT and what is relevant to patient care is staggering. I hope that discussions like these help us move forward.

[DanZ]

This is a timely blog as I was recently contemplating doing as you suggest, "firing" my (actually my wife's doctor).

My wife, Kerry, and I recently visited her obstetrician. During that visit, the obstetrician presented my wife with a myriad of potential screening exams available for pregnancy. To be honest I have not kept up with the various screening exams available during pregnancy; and there is certainly a lot more offered today than when I did my months of OB training during residency. So when Kerry turned to me to ask what she should do, I turned to the obstetrician and began asking her about sensitivity and specificity of the various tests. She gave me a quick reply that made it clear she had little understanding of screening exam parameters. When she left the room, I told Kerry how surprised I was that a physician who offers screening routinely has little or no understanding of the accuracy of the tests offered. Kerry told me that had I not been in the room with her should would have thought the physician recommended all the tests and gladly accepted the offer for all available tests.

When we left the office I reflected on why/how a physician could lack what I consider basic understanding of diagnostic testing. And, I recalled several moments from my medical training in which the de- emphasis on statistical understanding was apparent .

[Technogoggles]

I wonder to what extent the care you receive at different hospitals would play into the decision? There are general risks / benefits to treatment e.g. CT scans causing a greater risk of cancer but:

1. some hosiptals / surgeons (although I've only seen anecdotal evidence on a surgeon level i.e. "make sure you see blah blah she's the best surgeon for that") have a better record on invasive treatment than others
2. the care you receive - if the waiting list is 200% longer at a hospital with a slightly better record than one where the waiting list is shorter it also plays into your decision on health grounds - the problem could get worse in the waiting period.

Is Google working on developing the database you mention? To be able to provide the flip service to flutrends i.e. to get advice on benefits / risks of treatments would be incredible.

[sunnybunny]

With all the discussion regarding healthcare why are there not a million comments on this article? This is my primary concern when it comes to doctors and medical stuff. I don't want something done to me that is painful, unecessary, and likely damaging so some doctor can make more money or to cover his a$$.

[AJanson]

Interesting article, and a great idea. Part of my job as a genetic counselor is to review the benefits and risks (such as the potential for future insurance discrimination) of genetic testing. After going through the pros and cons, I'll ask patients whether or not they would like to proceed with the test.

From my perspective, the more informed a person would like to be, the easier my job becomes.
However, I sometimes find people confused by this process because it goes against the general flow of the vast majority of medical appointments. Also, there are some who would prefer not to hear all of the risks and benefits of testing, and would rather just be told whether or not to do the test. I personally believe that there is value in becoming a more informed patient, but I have learned to accept that not everyone feels this way. I guess the key is to find a physician who is willing to provide you with as much (or as little) information as you want and need.

[Roni Zeiger - Huffpost Blogger]

I agree that some patients are not as interested in weighing pros and cons and collaborative decision-making. I agree even more that the job of a good clinician is to provide as much information as the patient needs to understand the decisions they are making about their health.

[wazzat4u]

Thanks, Doc
I'm presently having an 'argument' with my doctor about his insistence that I get a colonoscopy.(I'm 70 yrs old). I want clarification about the dangers of biopsy. He says there are none. I've Googled 'biopsy and seeding' and find contrary evidence. I've lost a brother and a cousin to cancer. Both became raging cancer cases shortly after their biopsies, where they were 'fine' immediately before.
It seems that doctors look for where the body is 'broken' so they can write a prescription, rather than caring for the immune system. There has to be more to it than 'don't smoke and watch your cholesterol.'
I was also told that I had a diseased gall bladder when I passed a gallstone. Surgery was the only solution. I wish I'd gone to a naturopath or an Oriental doctor. I'd be healthier with my gallbladder.
I have a couple friends who say they defeated their cancer by controlling body pH, so I Googled 'cancer is a fungus'. Wow!

[joedecker]

This is a great article. I've went through a few doctors some years back trying to find a doctor who would actually proactively give me good and complete information about my health, risks and benefits, and once I found one I've stuck to her like glue. Amazing what a difference attitude makes in health care.

There's a particular aspect of colonoscopies that is often really undercommunicated--the usual forms of "conscious sedation" used for the procedure often involve a short-term amnesia around the procedure. It's utterly beyond my comprehension that a lot of patients are never told this, as a result, many end up feeling frightened, even traumatized by the experience and the unknown. ( http://colonoscopyblog.blogspot.com/2008/01/were-you-informed-when-you-were-given.html ) You'll do a big favor to a lot of folks if you let them know to ask about this, and make an informed decision, before the procedure. Thanks!

[Roni Zeiger - Huffpost Blogger]

Your point about conscious sedation is an important one. A trend I'm seeing -- and I think it's a good one -- is that it's becoming easier to find good videos on YouTube or elsewhere that show you what to expect.