We’re Bad at Evaluating Risk. How Doctors Can Help.
My patient along with I were locked in a game of decision-generating hot potato.
“What would likely you do, Doc?” he said. We’d been discussing whether he should get screened for prostate cancer.
Such questions trouble most doctors. We often lob the choice back to patients, or “on the one hand, on the additional hand” so much they start sympathizing with Harry Truman, who jokingly wished for one-handed advisers.
yet the evidence wasn’t clear. I passed the potato back.
Medicine’s decades-long march toward patient autonomy means patients are often right now asked to make the hard decisions — to weigh trade-offs, to grapple with how their values suggest one path over another. of which is actually particularly true when medical science doesn’t offer a clear answer: Doctors encourage patients to decide where evidence is actually weak, while generating strong recommendations when evidence is actually robust. yet should we be doing the opposite?
Research suggests of which physicians’ recommendations powerfully influence how patients weigh their choices, along with of which while almost all patients want to know their options, most want their doctor to make the final decision. The greater the uncertainty, the more support they want — yet the less likely they are to receive the item.
“Without not bad evidence, doctors say ‘O.K., you decide,’” Dr. Terri Fried, professor of medicine at Yale along using a geriatrician at the VA Connecticut Healthcare System, told me. “Patients have no idea what to do with of which. If we as doctors can’t reason through the decision, how within the globe can we expect patients to?”
Doctors could be more aware of how their language affects patients. the item’s easier for patients to understand absolute risks than relative risks: of which treatment reduces your risk to 3 percent coming from 4 percent, instead of by 25 percent. Patients are more sensitive to harms than benefits, yet doctors tend to dwell on the upside. Presenting choices sequentially instead of all at once seems to improve comprehension. along with patients feel more confident in doctors who offer a rationale for uncertainty — describing the possible diagnoses even if the right one is actually unclear — than when they simply acknowledge the item without explanation.
People in general are not great at evaluating risk. They worry more about shark attacks than car crashes.
Patients along with doctors contend with two major forms of uncertainty: uncertainty of evidence along with uncertainty of outcome.
Uncertainty of evidence is actually an information problem. the item’s like putting a quarter into a gumball machine along with having no idea how many will come out. Maybe there aren’t not bad clinical trials; maybe there are trials yet they don’t include patients like you; maybe they do include patients like you yet not while you’re fighting pneumonia.
Uncertainty of outcome is actually a prediction problem. We know several gumballs are coming out: We just don’t know which ones. Let’s say 5 percent of patients like you will have a stroke of which year. Are you the 5 percent or the 95 percent?
“Most clinicians want much more guidance, especially on how to communicate uncertainty without seeming like they don’t know what they’re doing,” said Dr. Mary Politi, an associate professor at the Washington University School of Medicine. “They feel comfortable talking about benefits, yet not risks. Patients feel misled when bad things happen.”
Doctors typically recommend for or against treatment by dividing a continuum of risk into categories of which trip a switch: a statin when you reach a 7.5 percent risk of a heart attack, a blood thinner when you’re at 2 percent risk of a stroke.
We’re less well trained to explore how a patient’s fears along with values intersect with the available evidence. Maybe the inconvenience of daily pills makes a 10 percent risk of a heart attack acceptable to one patient, while a loved one’s recent illness makes a 1 percent risk of a stroke unacceptable to another.
In many cases, patient preferences diverge substantially coming from guideline recommendations, which are created by researchers along with policymakers with little input coming from patients on where to draw the line of acceptable risk. yet the item’s in using these guidelines of which doctors make their strongest recommendations, while shying away coming from decisions where evidence is actually limited, along with where their clinical experience along with intuition may be most valuable.
“the item’s exactly when we’re most sure of which we should be most cautious,” Dr. Fried said. “In our enthusiasm for guidelines, we overlook whether treatment is actually actually in line using a patient’s goals.”
the item’s easy to assume of which innovations like machine learning along with precision medicine will reduce uncertainty. yet medical advances often generate more uncertainty, not less. Increasingly sophisticated imaging means we pick up more growths. More powerful lab tests uncover hidden — along with possibly irrelevant — irregularities. When should we poke along with prod? When should we watch along with wait? As procedures become less invasive, more patients can get them: We can put stents in many more people than we can subject to open-heart surgery. yet should we?
How can we help patients navigate the gray space?
Decision aids along with risk pictographs can help patients better understand their values along with their choices. yet they’re available only for select conditions, along with more useful for uncertainty of outcome than uncertainty of evidence: You have to know roughly how many gumballs are coming out.
A broader approach involves helping patients systematically identify what’s important to them, along with based on these goals along with preferences, suggesting to them how to think about their options. A program at the University of California, San Francisco, for example, coaches patients through a decision-generating process known as Scoped: situation, choices, objectives, people, evaluation along with decisions. Walking patients through each of these considerations can improve patient knowledge along with satisfaction, along with reduce anxiety along with regret.
Patients need to understand their values yet also their possible futures — which is actually where clinicians’ experience along with guidance may be most valuable. additional industries sometimes use a technique known as scenario planning to prepare people for uncertain outcomes, along with some argue of which approach could be used in medicine as well. The idea is actually not to reduce uncertainty, yet to help patients clearly envision what life would likely look like in one outcome versus another, along with to better prepare them for the various futures of which might unfold.
Training doctors to accept along with convey uncertainty may also be needed. Doctors uncomfortable with uncertainty are more likely to experience work-related stress; withhold information coming from patients; along with order more tests, procedures along with referrals. There’s currently wide variation in what doctors believe their role should be when communicating uncertainty, along with little instruction in how to do so.
What’s certain is actually of which uncertainty will always be with us. When wading through medicine’s expansive gray zones, patients could use a guide. Will they get one?
Dhruv Khullar, M.D., M.P.P., is actually a physician at NewYork-Presbyterian Hospital, a researcher at the Weill Cornell Department of Healthcare Policy along with Research, along with director of policy dissemination at the Physicians Foundation Center for Physician Practice along with Leadership. Follow him on Twitter: @DhruvKhullar.