Four Crucial Questions To Ask Your Doctor

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.

JMM

References:

  1. Hoffmann TC, Del Mar C. Clinicians’ expectations of the benefits and harms of treatments, screening, and tests: A systematic review. JAMA Internal Medicine. 2017.
  2. 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

10 comments

  1. Dr. John,

    Great advice as always. I think many patients assume their doctors are up to date with the latest medical literature and are well versed in statistics, however this is not necessary the case. Many doctors get caught up in fads/trends that might bias their views, whether it be ablation for Afib or the need for vitamin D supplementation in otherwise healthy people!

    With regard to Afib ablations specifically – one of the reasons given for early intervention is that allowing the condition to progress may complicate ablation outcomes if the procedure is eventually desired. This line of thought is prominent on the Afibbers.org site – an otherwise excellent source of information.

    I am in this quandary currently. I was diagnosed with lone (primary) Afib 3 years ago at 44 years of age. I had 3 episodes in the subsequent 2 years, but have had 7 in that last year. My episodes are short (<2 hrs) and asymptomatic, other than the anxiety in knowing all is not as it should be. My max HR in Afib rarely exceeds 120 and is often 10/yr) or prolonged than is currently the case before I ask my Cardiologist to refer me to an EP.

    Any thoughts you can offer would be appreciated!

  2. A few sentences were lost in the above comment, last paragraph should read:

    My max HR during Afib rarely exceeds 120 bpm and is often 10/yr) or become prolonged (>4hr) then I will ask my cardiologist to refer me to an EP.

  3. Seems use of ‘>’ results in lost text! One more attempt:

    My max HR in Afib rarely exceeds 120 bpm and is often under 100 bpm. My resting HR is in the 40’s. For the time being I have resolved to make lifestyle changes only, such as reduced intensity and duration of exertion, staying hydrated, limiting alcohol and swallowing liquids slowly, however if frequency and duration of events continues to increase, I will ask my Cardiologist to refer me to an EP.

  4. Love your “take” on how medicine should be practiced. I’m of the opinion we’re way too over-medicated — all ages, all maladies. We should supplement where needed; i.e., magnesium, vitamins C & D particularly. Let food be our medicine.

  5. Bravo, Dr Mandrola! Excellent article. It’s informative not only to patients, but, to other physicians, too. It’s very refreshing to hear a doctor expressing these views. I hope you always think for yourself—something which is not easy for doctors to do within the culture of modern medical practice. Thinking for oneself, strictly adhering to the dictum’ “first do no harm” while evaluating every option and recommendation in that light, taking the responsibility on oneself to be duly informed of all possible consequences of treatment (not relying mostly on the pharmaceutical industry, one’s colleagues, or common practice standards) and, putting the interest of the patients first–those are the principles doctors should stand on. It sounds like that is what you do.

  6. I agree, the right food can be the best medicine. Focus on building your immune system as preventative medicine. A doctor cannot write a prescription for nutrition and lifestyle changes and too often immediately chooses a pharmaceutical.
    We each need to take charge of our own health. Be proactive, ask your doctor questions and get a second opinion if needed.

  7. I have had a-fib for at least 5 years. Was on Carvedilol and Flecainide in the beginning. Then I heard about the Australian Legacy study. After talking with an EP who concurred that weight loss was as effective as ablation, I became motivated. I followed Dr Esselstyn’s whole plant food starch based way of eating without added oils, seeds, nuts, or avocado. 15 months later am down 83# and the Carvedilol is gone and Flecainide dose is 1/3 it used to be. My episodes are few and shorter and often halted with an extra dose of my Flecainide. I recently added in supplementary Magnesium too. Your reporting of this study initiated my starting this way of eating… no going back. Will I be able to ever outrun a-fib…. I have 25 more pounds to lose… just wondering. Thanks Dr. M

    1. To my knowledge, there is some evidence that avoiding obesity can reduce the chance one gets a fib,but there no evidence that getting thin and eating right will cure a fib. It is a little like avoiding smoking after getting lung cancer. Nevertheless, eating right and avoiding obesity is a good thing to do as it has many other benefits.

  8. Voltaire’s opinion about the art of medicine was made during his lifetime.He was born in 1694. At that time, no doubt he was correct. However, since that time there has been considerable progress in the art of medicine and today a physicians are obliged to do more for the patient than merely amuse him.
    I, for one, think this is a very very good thing.

  9. Lots to think about. I am moving slowly, trying to evaluate risk vs. benefit more clearly. Dr. john is a great source of common sense and a reality check specialist. His voice is much needed by people like me. Thanks Dr. john.

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