Wednesday, May 23, 2012

Trusting your doctor

One of the main things I do is to work with patients and families in education and making decisions.  It can be the most rewarding thing I do and the most frustrating.

I've learned something about the frustrating times-at some point, people have to trust other people.  Life works better that way.  Many times, patients and families don't trust their health care team (which is understandable-really).  But the way they compensate for that is by thinking they can learn the expertise to oversee the health care team and direct the health care team.  I get that as a sentiment.  It is intuitive, but impossible to carry out.

I'll give you a simple example, whether or not to take aspirin to prevent a first heart attack or stroke.  There are a handful of studies over the last 20 years that have gone into making the USPSTF guidelines.  There are newer studies coming out (1, 2, 3).  All have methodological/epidemiological issues (internal validity-is the study well done).  They all have external validity issues (application to a particular patient/population in the real world).  They attempt to communicate risk and benefit by using things like relative risk, Number Needed to Treat, absolute risk reduction, 10 year risk, risk calculators etc.

It takes a lot of thought to digest this info and then it has to be balanced against the evidence for blood pressure reduction, cholesterol reduction, healthy lifestyle, diet, smoking, other blood thinners like plavix etc.  To fully appreciate whether taking aspirin is "worth it" or not, a person would have to understand study design, statistical analysis and have a pretty comprehensive view of the literature and then be able to make rational sense of outcomes.  This is not easy to do and in fact I would argue for a lay person (or even a physician of the wrong specialty), this would be impossible to do for the simple question of whether someone should take aspirin.

Other questions that come up: should I start a treatment, should I get a diagnostic test, how do I navigate the health system etc are all very difficult questions with very nuanced, subtle, yet vital issues involved.

At some point, patients/families have to trust that the recommendation they are getting from their physician is a good one.  If they don't feel that it is, then they need to switch physicians because the solution of trying to know as much as the physician isn't realistic (or any more realistic than me understanding fully a legal issue or real estate issue or a car mechanic issue).

Too many times I've seen people make decisions badly when they are trying to be their own expert.  I suppose this is in response to many patients experience that the advice they receive from physicians can be worthless.  I get that.  It is hard to find a good physician.  But the solution to a lack of trust is to find someone to trust or to rebuild trust, not to create the facade of being one's own expert.

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