Risks and Tradeoffs
When it comes to cancer screening, preventive strategies and elective surgery, the message is..it’s all about the trade offs. When it comes to screening and prevention, are you okay taking a chance right now, today, to avoid an unlikely chance of being sickened or dying from a disease that’s decades away?
Are you about to subject yourself to harm or risk right this minute, while hoping for the purported benefits of an elective surgery that you signed up for later this week? Many are unnecessary and unproven. Some are even disproven but continue to be performed regardless.
Yes, a cardiac stent might relieve your stable, intermittent chest pain faster than medications. But you will need to take these pills anyway. But is the trade off worth the immediate risk of an invasive cardiac procedure? Most observers don’t think so.
Will you place a new born at the slightest or even purported risk for the sake of a convenience-based, scheduled Caesarean Section?
It’s conventional wisdom that B vitamins and omega 3 fatty acids prevent heart disease and promote ‘brain health‘.
Is it worth the trade off for an increase in cancers?
The general recommendation for patients with inflammatory bowel disease is that their colons be removed if there are signs suggesting a future risk of colon cancer. However, some patients disagree. In a survey of patients from two different referral centers, patients were asked how high a risk of colon cancer they were willing to take to avoid colectomy. Sixty per cent of patients responded that they would refuse the recommendation if there was a 20% risk of cancer. On average, they would only agree to the removal of their colons if the risk of colon cancer at the time of a finding of abnormal cells was at least 73%. Clearly, there is disagreement between recommended care and patients’ preferences. Who’s right? No one. There is only the combination of a patient’s risk tolerance made with knowledge of the facts. Facts that are clearly discussed and free of bias and techno-babble. Ah, well, this is a combination that’s hard to come by in offices today.
If a risk exacts a harm that’s reasonably likely, rapid in onset, and dramatic in its effect, the more it should be avoided. If you die at 80, it’s horribly sad. If you die at 50 trying to prevent that death, it’s tragic. If you die or are debilitated at 30 trying to turn back the clock, fix what isn’t broken or prevent an uncommon disease or one for which you are at no particular risk, it’s more than tragic.
How about taking a very low risk screening or preventive test today? What if it’s taken to prevent a somewhat unlikely but catastrophic problem that’s decades away? It’s a tradeoff that should be food for thought. Learn before you leap. Are you at particular risk? If so, the pretest probability might be high enough for you to consider it. If you are not risk averse, you are more likely to sign up. That’s fine. But if you are risk averse or the pretest probability is low, keep your pen in your pocket and tell you doctor to do the same.
Guidelines. Who’s doing the guiding?
What if the test is recommended on some guideline? Who’s it guiding? There’s more and more evidence that guideline worship helps your doctors’ incomes – not your outcomes. “Providers are promoting adherence to guidelines with steadily increasing pressure. Case managers have been hired to call patients and promote compliance. Reminders come in the mail. Primary care providers bring up the same overdue screenings at each visit. Some patients are grateful. Others want to be left alone.” “What if the patient does not want to change his or her behavior? Would true empowerment not allow for this scenario?” Not if doctors’ incomes depend on it.
And where do YOU draw the line? Some observers think following your doctors’ guidelines are a bad idea. Some call guidelines unethical and irrational. No, these are personal decisions and many guidelines are advertisements promoted by specialty societies.
Most medical decisions are personal choices. Subtract emergencies, infections and trauma and they are almost all subject to debate, have marginal benefit and are subject to personal preferences. It’s time to think of medical care as an exercise in choice. They are best driven by the knowledge of what you wish to trade off in order to achieve a goal unique to your needs and priorities.