Map of life expectancy at birth from Global Education Project.

Tuesday, June 02, 2009

Advice column

So Bix (who no doubt plays a sweet, hot trumpet) asks, given that doctors are overeager to do stuff to you -- whether because that's how they make their money, or it's just human nature -- and they aren't necessarily evidence based about the whole thing in the first place, what's a patient to do?

I usually try hard here not to be the Aunt Eppie of health care and public health: this blog is about policy and other big picture stuff. Nevertheless, since I brought it up, I probably do owe y'all my thoughts on this. As I keep repeating to the point of severe urtication, I'm not a real doctor, I'm a doctor of philosophy. So I'm not giving medical advice. Furthermore, whatever I suggest people do is not going to solve the problem because the vast majority of patients cannot or will not do it. The culture and the structure of medicine resist it, and anyway the average person probably shares the physician's proclivity for doing too much. So what, here goes.

First, I recommend that people get a hold of some important basic concepts. One is that the way risks are presented greatly affects how we interpret them. If I tell you that getting a mammogram will cut your risk of dying of breast cancer in half, you'll probably want to do it. But what if I told you that if 2,000 women are regularly screened for breast cancer for 10 years, precisely 1 will benefit by avoiding dying of breast cancer? On the other hand, 10 women who would not have died from breast cancer will undergo breast cancer surgery, and possibly radiotherapy or chemotherapy. What would your decision be? (NB: It's a different story if you have a family history or have never had children. Consult your physician.)

So one question to ask your doctor is, aside from relative risk or by what percentage doing something will reduce my risk, what is my absolute risk? If I don't do this thing, what are the chances that the bad thing will happen to me that it's supposed to prevent? And what are the chances of the bad thing happening anyway if I go ahead and do it? And what bad things might happen because of the intervention, and what are the chances?

Another way of looking at the kind of comparison is the Number Needed to Treat. How many people have to get this intervention to prevent a single instance of the bad thing happening -- be it sickness, disability, or death from the particular cause? And remember -- you will die anyway. It's a question of when and how. Nothing you can possibly do will "save your life." So what are you really trying to avoid? A lot depends on the age at which something is likely to happen, whatever other problems you may have at that time, and your personal preferences about what it's important to be able to do and how well you tolerate pain, and so on.

So when you are confronted with a choice, ask:

What are the risks of doing nothing? What is likely to happen if I just keep eating a balanced diet, exercising regularly, not smoking, avoiding excessive alcohol intake, wearing my seat belt, using condoms, and not keeping a loaded gun in the house?

What are the alternatives to the intervention the doctor proposes? And that includes interventions provided by people in other specialties -- if you're talking to a surgeon, he probably wants to do surgery, but there may be alternatives in physical therapy, pharmaceuticals, or who knows, meditation or cognitive behavioral therapy. Check them all out, Check with those other specialists; get a second or third opinion. It's usually sensible to start with the least intrusive, least expensive, and least risky option. Only when that doesn't work should you think about moving up the ladder.

Now, the cold hard fact is that there are some doctors out there who will not like it if you start asking them these questions. They will be offended, they will disdain you, they will treat you like a defiant child. In that case, just say thank you very much and walk out. Find another doctor, and another, until you find one who is happy to answer these questions; so happy, in fact, that even if she doesn't already know the answers, she will find them out for you. Which is obviously what she should have done before she made any recommendation in the first place. And then, if you finally decide no, I don't want that, accept no bullying, accept no scolding, accept no contempt.

On the other hand, if you do decide to undertake a treatment, you have to hold up your end. Take the pills, on schedule, every time. Do the exercises. Follow the diet. Keep your appointments. If you can't commit to it, it's the wrong choice for you, number one. And number two, I think you do have an obligation to your doctor if she or he is trying to do right by you. Doctors want to succeed, and when their patients don't cooperate by sticking with the plan, it makes them feel bad. At least the good ones. So it's a two way street. If they are listening, if they are giving you balanced and well informed advice, and they are letting you decide what's best for you based on that good advice, let them know you appreciate it. And do your best.

That's all I've got to say. Of course it's hardly ever going to happen.

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