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Wednesday, October 28, 2009

relieving suffering and reducing risks

Do patients actually know what they are getting from their doctors, and do they want it?

As I understand it, most patients want from their doctors primarily relief from suffering. And if they can't get relief from suffering, they would like to be heard and they would like to come closer to understanding the cause of their suffering.

When we prescribe cream for a rash, antibiotics for pneumonia or set a broken bone we are really right on the money. When we counsel and comfort we are doing the job we were hired for. When we get into the business of prevention, we are on a bit more shaky ground.

Much of our energy is spent haranguing, wheedling, threatening and assigning tasks. This is all in the service of preventing suffering, which isn't a bad goal when you think about it. We nag patients to take cholesterol pills, we assign them to go to obscure destinations to see specialists, we convince them to have painful and undignified tests like colonoscopies and mammograms. Many patients think that we are doing all of this to make them healthier, but that's not really it. The prevention gig is more of a very complex game of chance. A mammogram does not make a person healthier, in fact very much the opposite. Giving a person an 18 hour case of diarrhea followed by a potentially lethal dose of anesthetic, as is done for a colonoscopy definitely doesn't make a person healthier. Cholesterol drugs lower the risk of heart attack, and maybe strokes, but they don't make a person healthier. Their cholesterol numbers may be lower, but they are not healthier.

Much of this revolves around a rather abstract statistical indicator called the "number needed to treat." For many of the most accepted screening tests and preventive medications, the number needed to treat, which is the number of people who need to get the procedure or medication in order for one to not get the dire event it is meant to prevent, is anywhere for 20 on up to over 100. This means that 20-100 people have to do whatever it is in order for one of them to benefit. I guess you could say that everyone benefits, to the extent that they feel like they are doing the healthy thing, but I would say that's a bit of a stretch.

I don't mean to say that standard preventive medical testing and treatment is wrong, only patients need to understand that their chance of benefiting from these things, in actual fact, is nowhere near universal, and in many cases may be less likely than randomly pulling a one-eyed jack from a deck of cards. Costs, including the cost of loss of dignity and loss of time that could be spent on actual healing, need to be evaluated in this light.

Assuming, say, for treatment of high cholesterol, that the number needed to treat to avoid a heart attack is 20. The drug costs 100 bucks a month, and a person has to take it for 20 years. That's looking like over 20,000 bucks for a 1 in 20 chance of avoiding this dire event. Certainly something to consider. If the treatment costs only 5 bucks a month, the price tag is certainly more tolerable, and that represents the difference between a generic drug and a brand name. A certain number of people who take this drug will have a side effect, as well, and this human cost needs to be part of the equation as well. If the suffering and the money spent by all of the people who take the drug is less than the money and suffering of the one person who gets the benefit, then from a public health standpoint it is good medicine to encourage everyone with high cholesterol to take it. However, 19 out of the 20 people who take the drug are essentially "taking it for the team" and not actually doing any better than if they had avoided it all together. I am not entirely sure that people are aware when they take a drug or have a procedure done to prevent some bad health outcome that they are personally unlikely to notice any good effect.

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