Jun 17 2008
One of the criticisms of modern medicine is that doctors prescribe too many pills. That’s true. Patients and doctors sometimes get caught up in a mutual misunderstanding. The patient assumes that he needs a prescription, and the doctor assumes that the patient wants a prescription. But sometimes patients don’t either need or want a prescription.
I’ll use myself as an illustration. I get occasional episodes of funny, blurry spots in my visual field that gradually expand to a sparkling zigzag pattern and go away after 20 minutes. They are typical scintillating scotomas, the aura that precedes some migraines. I am lucky because I never get the headache. My doctor said we could try to prevent my symptoms with the same medications we use to prevent migraine, but there was no need to treat them from a medical standpoint. Nothing bad would happen if we didn’t treat. I told her I didn’t want them treated. They are a minor annoyance; I can carry on with my normal activities, even reading, throughout the episodes, and I have no desire to take pills with potential side effects and with the cost and the hassle of remembering when to take them.
If it had been a typical patient and a typical doctor, the sequence of events might have been very different. The patient might have been more frightened by the strange phenomenon than I was. (I thought the weird tricks my brain could play on me were fascinating and fun to watch, not scary.) The patient might have desperately wanted those threatening symptoms to go away without understanding how insignificant and non-threatening they really were. The doctor might have assumed the patient wanted them to go away. The pills might have been offered and accepted with little thought.
A woman goes to her doctor complaining of nausea and vomiting. She wants to get something to stop it. She finds out she is pregnant, and it’s only morning sickness. Her whole attitude changes; now she is happy to put up with the symptoms. She wouldn’t want to take anything that might harm her baby.
When a patient goes to a doctor, he doesn’t necessarily want treatment. He really wants answers to these questions:
What is causing my symptoms?
Is it serious?
How long is it likely to last?
How can it be treated?
He may ask about the side effects of treatment.
He is less likely to ask one other crucial question: what would happen if we didn’t treat at all?
Here’s a scenario that plays out in doctor’s offices thousands of times every day: a patient has cold symptoms. Maybe he’s afraid it might be something more serious than a cold, like a sinus infection or pneumonia. Maybe he thinks the doctor can cure his cold with antibiotics or some other new remedy. The doctor examines him and reassures him that it’s only a cold. He knows there is no treatment that will make the cold go away any faster, but since the patient has gone to all the trouble to come in for an appointment, the doctor feels a little embarrassed about telling him it’s trivial and sending him away with nothing. He gives him a decongestant and some Tylenol. He knows they won’t do a thing to affect the course of the cold but hopes they may help relieve some of the symptoms. He has the feeling that in this social interaction he is expected to give the patient a token, in this case a prescription. The patient has the same feeling: that he ought to get something to take home. Both the doctor and the patient think the doctor ought to “do” something. (These are not the bad doctors; the bad ones prescribe antibiotics or homeopathy or something equally nonsensical.)
What if every doctor explained that there was no effective treatment, that the symptoms would subside in a week with or without pills, and that symptomatic treatment wouldn’t help much and carried a small risk of side effects? The patient would then have the chance to say, “I want something to take even if it’s no better than placebo” or “I don’t really need to take anything. I just wanted to be sure it wasn’t something serious.”
When a patient has a high LDL cholesterol and other risk factors for heart disease, especially if he has already had one heart attack, some doctors assume they should prescribe statins, and patients assume they should take them. The reality is that most patients who take statins will probably not benefit from them. Instead of a knee-jerk grab for the prescription pad, a thoughtful doctor could look up the NNT (number needed to treat) and NNH (number needed to harm) and tell the patient something like “For your particular risk group, 84 patients need to take statins to prevent one death from heart attack, and of those 84 patients, 3 will have serious but not life-threatening side effects.” (I’m just making up these numbers.) Some patients will think “I might be that one patient whose life is saved” and will want the pills. Others will opt not to treat, thinking they are more likely to be one of the ones with side effects and/or no benefit.
Neither course is unreasonable; the choice depends on things like the patient’s philosophy, his degree of optimism, his fear of death, and his willingness to take risks. One way to look at it is that statistically a group of people on statins will live longer than a group not on statins, so the doctor should offer them to the group. Another way to look at it is that if 84 patients chose not to take the pills, one would have guessed wrong and would have a heart attack and the other 83 would have guessed right. (Of course, the situation is really a bit more complicated, because statins may have good or bad effects on other parts of the body besides the heart, and there are other things to consider like cost and interactions with other medications the patient might be taking and the patient’s ability or willingness to work on reducing other risk factors.)
In my article on “Reading the Medical Literature with a Critical Eye” I discussed an article about t-PA treatment for stroke. “The bottom line is that one in eight patients is helped at three months, one in 17 is harmed, and although the randomized trial showed no increase in mortality, there has been a documented increase in death rates in patients who have received t-PA therapy outside of research trials.” There is room for disagreement, but many people would agree that not treating is the better option.
Early stage prostate cancer is another real dilemma. It may be slow-growing, and the patient may die of other causes before the prostate cancer can kill him. Should you try to eradicate the cancer with surgery or radiation, with a significant chance of complications like impotence? Or is conservative management reasonable (surveillance, watching for a rise in his PSA levels)?
Are your knee joints kaput? Joint replacement surgery is an option. Medical treatment with drugs like NSAIDS or narcotics is an option. Non-treatment is an option too – maybe you would rather give up sports, avoid stairs, and accommodate your lifestyle to your limitations.
Another personal example: when I had a breast biopsy, I chose local anesthesia because I thought it was safer than general anesthesia. The anesthesiologist agreed, but said he would use IV sedation along with it. I asked him why. He said to control my anxiety. I told him I wasn’t anxious and didn’t want it. We negotiated, and finally he agreed not to give me a sedative before the surgery and I agreed that he could give it at any time during the procedure if he thought I seemed anxious or my BP rose too high to suit him. It was probably the first time in his career that he had omitted routine IV sedation for a procedure like this. All went well; I wasn’t anxious, we chatted throughout the surgery, and my time in the recovery room was minimized.
IV sedation is a good idea for the average patient, but not every patient needs or wants it, and it’s nice to have the option of no treatment. My anesthesiologist would never have even considered that possibility if I hadn’t spoken up.
Of course, non-treatment is not always a reasonable option. If a patient has severe diabetes and doesn’t get insulin, he will die. I’m not talking about those cases. But even in those cases, the principle of autonomy gives the patient a choice. Every surgeon has had an occasional patient who refuses life-saving surgery with the full understanding that it means he will die. If the patient is mentally competent, he has the legal right to refuse any treatment.
Think of the many self-limiting minor illnesses where non-treatment IS a reasonable option. Things like colds, common backaches, headaches, earaches, sore throats, gastroenteritis… many of the most common reasons for doctor visits. If the doctor rules out a serious condition, there is no need to take pills for symptoms that are expected to subside on their own. The patient may prefer to try simple comfort measures at home. I’m rather fond of the old remedy for a cold that says to go to bed, put your hat on the bedpost, and drink whiskey until you can’t see the hat. That’s a joke; but seriously, “tincture of time” is a treatment with no side effects: it’s the safest and cheapest remedy of all.
I have had lots of patients tell me “It doesn’t really bother me that much. Now that I know it’s nothing serious I’m happy to put up with it. I don’t need to take anything.”
So this is a plea to doctors and patients alike: when you’re considering treatment options, keep non-treatment on that list of things to consider. Let’s destroy the myth that the doctor always has to “do” something.
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