Doctors must give patients more help with medical uncertainty and complexity

roulette-300x188Although Americans may love to wager on ponies, lotteries, and even church bingo games, they’re getting restive and confused about playing the odds with their health — and doctors need to step up their game a lot to help patients better cope with medical uncertainties.

Dhruv Khullar, a physician at NewYork-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy and Research, has written an excellent piece for the New York Times’ evidence-driven “Upshot” column, detailing a modern, thorny part of doctor-patient relationships:

Medicine’s decades-long march toward patient autonomy means patients are often now asked to make the hard decisions — to weigh trade-offs, to grapple with how their values suggest one path over another. This is particularly true when medical science doesn’t offer a clear answer: Doctors encourage patients to decide where evidence is weak, while making strong recommendations when evidence is robust. But should we be doing the opposite? Research suggests that physicians’ recommendations powerfully influence how patients weigh their choices, and that while almost all patients want to know their options, most want their doctor to make the final decision. The greater the uncertainty, the more support they want — but the less likely they are to receive it.

He says this quandary arises with matters like medical screenings ─ whether men, for example, should get tested for prostate cancer, an issue that prominent experts say is overdone, while others disagree.  Khullar says he can try to explain medical rationales, even offering mathematical expressions about predicting outcomes. These don’t always help much, say when discussing patients’ use of statins to lower blood cholesterol.

One such metric, the Number Needed to Treat or NNT, is a good one, and I’m an advocate for its simplicity and clarity. As I’ve written of the NNT:

It asks the question: How many people need to get this particular drug/test/treatment in order for ONE person to benefit? The lower the number, the better.  If the NNT of a treatment is one, that means everyone treated is helped. One person treated equals one person’s life made better. But that’s true only for imminently life-threatening conditions when everyone dies who is not treated: like an appendix about to burst or a heart that has stopped beating and needs to be shocked back into rhythm. For every other medical condition, the NNT is higher than one, sometimes a lot higher. Screening tests for early detection of cancer frequently have NNT’s in the thousands: one person’s life saved for every few thousand tested.  That can be worthwhile, as long as there is little harm inflicted on the thousands tested. But the reason the PSA test for prostate cancer was recently nixed by the US Preventive Services Task Force is that it not only had a very high NNT — 5,000 or even higher — but also because the test inflicts a lot of harm in the downstream consequences when a man learns he may have early prostate cancer. For every life that may be saved, dozens of men are killed or maimed by the surgery.

Khullar sees value in this metric, and visual depictions of it and others like it. But he also notes that emotion and innumeracy can be obstacles to patients dealing with medical uncertainty with logic and clarity.

Those are issues underscored by an Op-Ed piece, also in the New York Times, by Robert M. Wachter, a physician who specializes in care for patients in hospitals and studies how to make hospitals safer and more efficient. He notes that he often must assist patients with advanced cancers. And while headlines daily describe advances in the field, notably immunotherapies or getting the body’s own systems to successfully wage war on certain cancers, it also is true these treatments are costly and, for now, constrained. They don’t work for everyone. And many cancer patients, ill and weakened, and their families, too, struggle with a seeming one-or-the-other choice: Try new, invasive, late-stage therapies, or seek “comfort” or palliative care that seeks to ease patients’ major pain and unease?

Wachter says, actually, both can occur together. That still doesn’t resolve the uncertainty that cancer patients wrestle with, trying to wager, effectively, their lives and their family finances and not knowing what’s convincing to do so, given that many cancer drugs may extend their lives only briefly and at astronomic cost.

In my practice, I see not only the big harms that patients suffer while seeking medical services but also their heart-wrenching struggles to access and afford safe, quality, and excellent medical care. Medicine gets more complex by the day, with a chunk of it needless and wasteful. Patient-consumers get bamboozled and bombarded with harmful hype in news reports on medical-scientific matters, with doctors, hospitals, and research institutions trumpeting their work, often to boost their profit and professional standing. Even in matters affecting diet, an area where common sense should seem easily to trump a flood of bunk, the consumers who might be assumed to be most savvy — those more affluent and better educated — are too easily gulled.

Khullar and Wachter both make the case, rightly, that doctors need to make big improvements in how they provide the fundamental patient right of informed consent. This is critical for all of us: It’s every health care provider’s duty to ensure that you know fully your treatment options and that you decide what path to take, without strong-arming or scare tactics from the person in the white coat. This also means that doctors need to stay up to date, so they can discuss with you, cogently, medical changes and advancements and how they may affect you. They also need to lessen their profit-seeking and to stop dashing from examining room to examining room, devoting too little time to you, your appropriate questions, and most important, the quality of your care.

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