The medical decision as a gamble

The medical decision–to have a screening mammogram, to take warfarin, to undergo a catheter ablation–is, at its core, a gamble. We pit the treasure of the win (benefit) against the pain of the loss (harm).

In times past, medical gambles were easier. You took the antibiotic or you lost your leg. Most medical decisions today are hardly that clear. We say they are preference-sensitive.

Many factors determine these preferences.

The digital revolution notwithstanding, what a patient prefers turns substantially on how the decision is framed. (Wear this vest or you could die.) How the decision is framed depends on the doctor’s preferences. What a doctor prefers turns on how key opinion leaders and policy people think. (Get blood pressure to this level.) How key opinion leaders and policy people think depends on a lot of things, maybe even their industry relationships. And so on.

It is like a symphony of human behavioral psychology. A gumbo of bias. (Grin.)

I read two articles today that made me think about the act of deciding things in medicine.

Drs. Aaron Carroll and Austin Frakt wrote in the New York Times today about the way we measure a treatment’s potential for harm. I am drawn to this sort of work because harm avoidance is a core feature of heart rhythm care. Their pictorial of the benefits and harms of screening mammograms underscores something I preach everyday: all medical decisions are a gamble.

Here is the risk quandary for AF:

Dr. Scott Aberegg is a medical doctor in Utah who writes the Medical Evidence Blog. In this post, he takes an interesting view on how the NNT (Number Needed to Treat) statistic can get patients into a Therapeutic Paradox–where what is good for the population may not be good for the individual. (e.g. the voter’s paradox).

Treatment A offers you only a 0.1% chance of benefit. But that tiny fraction adds up if applied to a population of millions. When I questioned the benefits of statin drugs for primary (not secondary) prevention, more than a few commenters used the population-benefit argument. And they are right, sort of. The problem is that populations do not sit across from doctors in the exam room.

It gets back to the symphony of decisions. Health policy leaders–those who influence doctors–might see the gamble of certain treatments from a different perspective than a person swallowing the pill. I like this quote from Dr. Aberegg:

“if we treat 33 people with coumadin, we prevent one stroke among them…A person trying to understand stroke prevention with coumadin could care less about the other 32 people his doctor is treating with coumadin, he is interested in himself.”

Dr. Sergio Pinski’s response to my Tweet captures the essence of the doctor’s role. I referred to the power we hold as framers of the gamble.

@drjohnm @EJSMD we are choice architects.

— Sergio Pinski (@SergioPinski) January 27, 2015

Architect (second definition) — a person who is responsible for inventing or realizing a particular idea or project.

When doctors discuss and recommend actions, they engineer a choice.

When patients decide to have the test or take the treatment, they enact the wager.

Does everyone understand the odds? Are we clear about who wins and who loses?

More important, and this is key:

Do we even think of this act as a gamble?

JMM

P.S. Here are 146 other reasons to see the medical decision as a gamble.

H/t to The Healthcare Blog, who reposted Dr. Aberegg’s piece.