The Upshot reflects: Patients overestimate benefit and underestimate harm of tests & treatments

In February, an excellent systematic review article appeared in JAMA as part of their "Less is More" series. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review by Drs Tammy Hoffman and Chris Del Mar provides a comprehensive overview of patients views of the risks and harms of various tests, procedures, and treatments.

Their Conclusions and Relevance section explains the take-away it nicely:

The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.

This week, the NY Times Upshot - a source I'm finding myself reading more and more often - posted their reflection on the article, If Patients Only Knew How Often Treatments Could Harm Them. They beautifully wove together some of the data from the article to make it easier to digest and understand.

For example, they highlight the 2012 Annals of Family Medicine study that looks at patient estimates of the benefits of screening for bowel cancer. 

94% of patients overestimated the benefits of bowel cancer screening.

Simple and persuasive examples like that help explain the problem with our current care, and the article culminates in a summary written by Drs Frakt and Carroll that is completely in line with the principles that drive the Less is More in Medicine approach:

Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

Since they've done such a great job expounding the article, I feel no need to provide my own explanations or reflection.

 These kinds of articles come into my email and RSS reader and across my twitter landscape in droves; being overrun with articles and action in the field of overdiagnosis/testing/treatment is a delightful problem to have.


Doctor, Shut Up and Listen (NY Times)

You've heard it 100 times, but perhaps this time it will sink in.

There's really no substitute for taking a thorough history of a patient and then supplementing it with a targeted physical exam, before considering any tests or interventions.

I'll admit, sometime I scrimp on the history (see below). I hate doing this because there's GOLD in the patient's words. You kind find out who they are, what is bothering them most, what they think is going on, and what you ought to do about it.

This is free, grade A info, and the only cost is time; filtered through a fancy medical education, what the patient says will guide everything. 

In the article Nirmal Joshi highlights the horrific results of crappy encounters:

Brief, rushed physician encounters were common, with limited opportunity for questions. A lack of empathy was often apparent: In one instance, after a tearful patient had related the recent death of a loved one, the physician’s next sentence was: “How is your abdominal pain?”

This past week, we were in the throws of influenza at our hospital. We still are. It was also the holidays and without the regular compliment of physicians, let alone Social Work, Occupational Therapy (OT), Physiotherapy(PT), Patient-Care Coordinators (PCCs), Speech Language Pathologists (SLPs), porters, Radiology Technicians, Phlebotomists, Pharmacists, etc. things basically ground to a halt. 

A lack of personnel and resources, combined with high numbers of new admissions, meant that everyone on my team was covering more than the usual number patients of varying acuity. And this, without the benefit of the usual allied professional help and expertise that we are dependent on working with to deliver high-quality care. So, time was limited. Simple questions to patients would be asked wherever possible, but I would never have left the building if I was being as thorough as I usually am. 

On the day where I started with a ward emergency (patients O2 Sats were 64%), I didn't eat lunch or take a bathroom break, another patient had new neurological symptoms and needed STAT imaging (and I got the radiologist to authorize it, but it still took 6 hours), a few other SNAFUs, and I stayed much later than usual, I simply could not find the time to practice a good 'ole H&P on every patient who warranted it. And I was very hungry!

I remember one patient with a complex story who was in for reason X but also happened to have problem Y (which was improving with treatment, but was initially life-threatening). The focus was on stabilizing the problem, which was actually going well. I expected the problems were related, and I could figure this out with a simple urine test. I did take the time to ask the patient about health problems, changes in medication, and to review the notes from specialists over the past year. But, with my phone ringing off the hook and patients needing to be seen, I didn't take the time to ask about some simple symptoms that might have helped steer the boat and figure out why Y had happened in the first place. I just ordered a lab test.

This is not something to be proud of, but I can certainly see how "Less is More" is sometimes easier said than done. I'm glad I'm conscious of the right way to do things but it is hard to always do that. Trying to find a balance between the mixed messages of "physician wellness is important" and "do everything beyond humanly possible to help people" makes it hard to end the day on a good note. 

I wish the system was structured in a way that the time and other pressures facing us didn't create situations where we have to choose between keeping sane (eg. taking a break) AND doing the right thing.

I'm nowhere near perfect but I really do enjoy getting to know my patients and playing "detective" to try to diagnose and treat their issues.

A lot of days, I miss my lunch.


Read the NY Times article HERE.


Believing in Treatments That Don't Work

Dr David Newman considers the example of Beta-Blocker medication use in patients with heart attacks. Studies show that using these medications might make patients with heart attacks go into heart failure, rather than protecting the vulnerable heart. He cites numerous other examples of treatments that make sense by deductive reasoning, but aren't in fact beneficial.

Ideology trumps evidence . . .

Treatment based on ideology is alluring. Surgeries to repair the knee should work. A syrup to reduce cough should help. Calming the straining heart should save lives. But the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications.

Read more on the Well Blog of the NY Times.