Monday, June 29, 2009

Weighing options of treatment

While I don't plan on writing daily updates until August, I figure that I want to get in the habit of writing thoughts down when they occur. Over the weekend I met a lady who is 73. She has severe osteoporosis but because she has bad side effects to oral bisphosphonates, she does not want to try even an intravenous bisphosphonate. Instead, she was trying an unproven combination of Evista and Calcitonin nasal spray. This lady is not one of my patients. She told me she has lots of medical people in her family and on their advice, she decided that the risks of using an IV bisphosphonate like Boniva or Reclast was not worth the benefits. It's not clear to me what she perceived the risks and benefits to be or how she came to that conclusion. She may be right, she may not be but it did make me reflect that how people make medical decisions is really really interesting.

The way physicians make decisions is they use studies to try to quantify the risks and benefits and if the benefits outweight the risks (and don't cost too much), then it's the right decision to try the treatment. If the risks outweigh the benefits, then it isn't. There isn't a lot of emotion in the decision. In the situation that there is no evidence, or poor evidence, then the situation is tricky.

The way I see it, which is limited I'm sure, patients make decisions quite a different way. Most patients don't have access to the studies, or have trouble making sense of the medical literature. There are several categories of decision making process that I see patients go through: some try to weigh risks and benefits as interpreted by their physician, some decide based on what they fear more (fracture or side effects), some by gut feeling, some by cost, some by what somebody famous says or by what family says. In other words, patients look to a different source of authority for decision making information.

What's challenging for the physician (and patient) is to bridge this gap. As I write about different issues, I hope to give the information needed to help any person make an educated decision regardless of decision making style. We'll see how it goes!

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