How do doctors decide on treatments?
How do you decide? And yes, you should decide!
What inputs go into making this important decision?
Let me make it simple. Basically, there are only four. (As they say in the Hamburg EP labâ€¦â€Itâ€™s easy.â€)
First, since I am an older doctor, Iâ€™ll start withâ€¦
In deciding on a proposed treatment, there are two important risks to balance: the risk of the treatment versus the risk of the disease (or the potential of disease in the future.) Some examples might help: During a heart attack, a life depends on what happens in the next 90 minutes. Angioplasty and stenting, done swiftly, saves lives. The procedure, and its necessity to use blood thinners incur the risk of serious complications. But the risk of the heart attack is worse. So most gladly accept the stent. Thatâ€™s easy; the risk of not treating dwarfs the risk of treatment. The same goes for the risk of antibiotics: when redness streaks northward from a leg wound, antibiotics sound pretty good. For the snotty sniffles, that’s another matter.
These are easy cases.
Let’s plug-in statins: Take the patient with high cholesterol but no other risks for heart disease. As most know, future heart disease risk depends on many other factors besides cholesterol levels; smoking, diabetes, blood pressure, body weight, and genetics all determine future risk. Those patients with only high cholesterol as a risk factor have very low 10-year risks. Thatâ€™s the issue with treating cholesterol in low-risk patients; itâ€™s difficult to lower an already low chance of an event. Though mostly safe, even the small risk of a statin drug, when compared to the small benefit, tips the balance towards not recommending the drug. Complicating this decision further is the presence of alternative treatments; smart eating and regular exercise place a patient at ZERO risk. But, as risk increases so does the benefit of statins.
The second variable in making medical decisions involves weighing the benefits of treatment. These can include improved quality of life, quantity of life or ideally, both. This can get tricky. A doctor can help, but patients can help themselves by doing homework.
Letâ€™s use another heart disease example: Catheter ablation offers symptomatic patients with medically-resistant AF the best chance of an improved quality of life. Thatâ€™s all we can say. We cannot take the next step and argue that relieving symptoms of AF translates into lower risk of strokes and deaths. The benefit, therefore, is relief of symptoms only. But what if the AF patient reports no symptoms? A tough call. Tougher even, if itâ€™s a young patient who will have to live an entire life with AF.
Doctors owe it to patients to give a candid, realistic and evidence-based description of the benefits of treatment, or no treatment. A patient that asks informed questions stands to gain a clearer picture. Ask me what the evidence says about AF ablation, about AF meds, or about anything I recommend. If I donâ€™t know, Iâ€™ll say.
At minimum, every medical decision has two options: treatment or not. Itâ€™s always illuminating to consider the no-treatment option. Two examples: When recommended a blood-thinner, an AF patient has two alternatives: by taking the drug they risk a bleeding complication and by not taking it, they risk stroke. My job is to mesh the specific details of each patient with my knowledge of the evidence and then provide the patient options. The unsteady elderly face tough alternatives: a greater risk of traumatic bleeding during a fall versus huge reductions in stroke risk. The cyclist on blood-thinner too: the small risk of bumping the head in a crash versus the also small risk of stroke.
Another good example of presenting (multiple) alternatives comes when an athletic patient develops AF. Here, the typical first choice, using an AF drug is often poorly tolerated, or risky because some of these drugs can cause dangerous rhythm problems during big physical efforts. The alternative is ablation, but ablation is a big procedure with inherent risks and some say, less than ideal results. Alas, the third alternative: put up with the AF and adjust to a different way of life.
The murkiest area of medical decision-making is communicating expectations. (Smart people call it nuanced.) This expectation thing is a hard one to get just right. Some doctors over-promise and under-deliver, while others under-promise so they can over-deliver.
To illustrate gray areas, nothing clouds like the use of defibrillators (ICDs). These expensive, risky devices are installed to prevent one from dying of an arrhythmia. But to benefit, the patient has to be sick enough to be at risk of sudden death, but not so sick to be dying of something else. But how sick is too sick and how well is too well, are far from binary calls. And the alternative to having an ICD, not having one, well, that depends on how the patient wants to die. Try sorting this out in a twenty-minute office visit, or at the bedside of a semi-private hospital room. â€œWhat did you say docâ€¦I am going to die sometime?â€
Itâ€™s (pretty) easy.