Patient Acceptance of Medical Risk

November 1, 2016

I won't talk a patient into treatment, yet, I do have a superior level of expertise. My goal is that patients understand risk, benefit, and alternatives.

I am fascinated with the concept of risk. A number of years ago, I had a grizzled older gentleman who was discussing an upcoming surgical procedure with me. He had bilateral leg amputations and continued to smoke. He was going into the procedure with an increased risk of complications. As I was trying to explain the risks and benefits, he stopped me to ask, "So, doc is it at least 50-50?" He was fine if there was at least a 50 percent chance he'd survive the surgery, despite the fact that I think most surgeons would avoid a surgery with that type of mortality risk.

More recently, I've been having discussions with patients about the risks of statins or not taking statins, having prostate cancer screening, and the danger of uncontrolled diabetes. One of the more standard conversations I have is about statins. There are clear guidelines about who is most likely to benefit from primary prevention with statin use. I've started using a web-based, patient-facing risk calculator that goes through the risk of heart disease and stroke both on the medication and off the medication, as well as a relative hierarchy of possible side effects and costs.

Some patients are highly likely to benefit from statins. Their 10-year risk can decrease by half, yet, they do not choose to start a medication. In other instances the overall benefit may be quite small, but patients choose the statin. There are obviously multiple factors that go into play, but why some patients choose a medication that affords little benefit and others eschew treatment that has significant benefit puzzles me.

It is always a good idea to figure out what patients value. Some patients highly prize taking few if any medications, even when there are inexpensive, safe, and effective therapeutic options. Other patients want to get better in the easiest way possible and will gladly choose a pill over lifestyle change. Most are somewhere in the middle - they'd like to avoid a medication (or surgery or treatment) if at all possible, but will accept it if there is benefit. Our job as prescribers and physicians is to accurately portray risk, benefit, and alternative options to our patients. This is a challenging task. Most medications have many, many potential risks. Do I describe those that occur 10 percent of the time as well as those that occur 0.1 percent of the time? How do I accurately explain the concept of number-needed-to-treat to illustrate that not every patient will benefit from a treatment? Alternatives to treatments are also challenging to discuss since there are both risks and benefits to all of these options.

Most of us do our best with the time we have to give accurate but not overwhelming information. The truth is that statistical analysis looks at a population, but our patients look at the person who stares back at them from the mirror. A complication is not rare if it happens to you. Likewise, a treatment that cures only 1 percent of the time is great if you are that 1 in 100 patient.

I do not want to talk a patient into anything, but I do have a level of understanding and expertise that cannot be condensed into a three-minute explanation. My ultimate goal is that a patient perfectly understand the complexities behind risk, benefit, and alternatives. To that end, I will continue to try to solve the mystery of risk acceptance and avoidance one patient at a time.