I am seeing an increasing number of patients who did not know they had a choice about taking a medicine or having a procedure.
- Why did you have that heart cath? A: My doctor said I should.
- Why are you on that medicine? A: My doctor prescribed it.
It’s time we re-review the basic four questions you should ask your doctor.
I wrote about this in April of 2015 for WebMD. Here is 2017 update:
1. What are the odds this test/medicine will benefit me?
Medical decisions are like gambles. Benefit is not guaranteed. In my field, catheter ablation of supraventricular tachycardia (SVT) has a success rate approaching 99%, but the success rate for ablation of atrial fibrillation or ventricular tachycardia is much lower.
Another aspect of discussing benefit is defining what is meant by benefit.
Statin drugs, for instance, are quite good at lowering cholesterol levels, especially LDL, the bad cholesterol. But LDL is what we call a surrogate marker. Having a lower LDL is supposed to deliver future benefit–say a lower chance of a heart attack, stroke or death.
If you don’t have heart disease, just a high cholesterol level, your future benefit of taking a statin is small. Abramson and colleagues, writing in The BMJ, estimated the average future benefit of statins in low-risk patients to be in the range of a 7 in a 1000 risk reduction of a non-fatal event over the next five years. That means that about 140 patients have to take a daily statin to prevent a heart attack or stroke in one patient. Is that small but statistically significant benefit worth taking a statin? That’s up to you–not your doctor. (Note: the risk reduction with statins is higher if you have established heart disease.)
Another example in the news lately is the benefit of PSA screening for prostate cancer. The USPSTF, a major governmental guideline committee, recently changed the recommendation for PSA screening in younger men from a D to a C. In one sentence, the benefit of PSA screening is that it reduces your risk of dying from metastatic prostate cancer by about 1 in a 1000, but that small risk reduction does not translate into a survival advantage overall. (See oncologist Dr. Vinay Prasad’s review here.)
2. What are the downsides or harms of the test/medicine?
No intervention in the practice of medicine is free. Here I don’t mean costs, I mean harms. You can’t have an ablation without incurring the risk of procedural harm; no doctor is perfect. You can’t take a drug without exposing yourself to the potential toxicities of the drug. (Even antibiotics come with the risk of severe allergy or secondary infection with Clostridium difficile colitis.) This is where you need your doctor to help balance the probability of harm versus the probability of benefit.
An important warning though: Doctors under-estimate harms and over-estimate benefits. I recently wrote about a systematic review from two Australian researchers which showed clinicians rarely had accurate expectations of benefits or harms, with inaccuracies in both directions.(1) This group has also found patients, too, over-estimate benefit and under-estimate harms.(2)
3. Are the simpler safer alternative options?
When I explain options to patients, I always tell them there are alternatives. An alternative to catheter ablation is an attempt to control the rapid heart beat with a medication. In heart disease prevention or treatment, one of the most common alternative therapies is an improved lifestyle. For instance, the alternative to taking a statin drug for cholesterol or a blood pressure drug for hypertension, is a better diet, weight loss and more exercise.
4. What happens if I do nothing?
As mainstream medicine increasingly medicalizes much of the human condition, this last question grows in importance.
The famous French philosopher Voltaire said that the art of medicine consists in amusing the patient while nature cures the disease. Time is an underused tool in the treatment of illness. Despite our dominance as a species, patients and doctors underestimate the ability of the human body to heal itself. The main advantage of watchful waiting is that it allows patients to avoid harm from healthcare.
Another aspect of not taking a drug or not having a procedure is living with the condition. This comes up a lot in atrial fibrillation care. Sometimes, often even, the presence of atrial fibrillation episodes does not diminish the quality of life enough to warrant taking the risks of treatment–say drugs or procedures. It’s a very similar story in surgery: maybe the hernia or inflamed joint bother you, but not enough to have the surgery.
- Hoffmann TC, Del Mar C. Clinicians’ expectations of the benefits and harms of treatments, screening, and tests: A systematic review. JAMA Internal Medicine. 2017.
- Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175:274-286