Risky business

As I sat in a corner of the waiting room and perused the consent form, alarming words and phrases leaped out at me. “We cannot guarantee…” “… rare complications…” “… risk of death…”

It made me seriously wonder if I was making a mistake by subjecting my cat to anesthesia in order to have her teeth cleaned.

In the end, the risk seemed small and not enough to outweigh the benefits. But just the same, I handed her over to the veterinary tech with a pang of misgiving. Even a small risk doesn’t mean there’s no risk at all. If complications are going to happen, who says it won’t happen to you?

When you get right down to it, much of health care decision-making involves a series of calculated risks, a complex set of tradeoffs. This treatment for that benefit. This medication for a reduction in the chances of having a heart attack. These antibiotics, and the side effects that go with them, in exchange for getting rid of a bacterial infection. This conservative watch-and-wait approach vs. prompt and possibly unnecessary (and expensive) intervention. This risky surgery in hopes of saving the patient’s life.

Yet how we perceive risk vs. benefit often tends to be highly subjective. What some people view as reasonable might be viewed by others as too aggressive or perhaps not aggressive enough.

I’m eagerly waiting to get my mitts on Dr. Jerome Groopman’s latest book, “Your Medical Mind.” Co-written with Dr. Pamela Hartzband, it’s subtitled “How to Decide What Is Right for You” and explores how our beliefs, values and past experiences help shape the health care choices we make. (A review of the book appeared last weekend in the New York Times.)

Are you a minimalist who prefers to avoid procedures and pills unless they’re totally, absolutely necessary? Or do you believe in seeking out the latest technology or treatment that science can offer?

People can be unconsciously swayed by factors they might not even recognize – pharmaceutical marketing that plays up the effectiveness of a new drug, for instance, or a relative’s previous frightening experience with a surgical procedure that went awry. Over the years I’ve had other cats who had to be lightly anesthetized for a dental cleaning. They emerged a little bit woozy but were safe and sound and soon recovered. This helped reinforce that it was an acceptable risk to take. My perception might have been entirely different if I’d had the experience of losing a cat who stopped breathing under sedation.

We are not, in fact, entirely rational in how we assess our health risks. Via MinnPost, I came across an article from Discover magazine that delves into the conflict between our gut and our brain. Author Jason Daley describes how we fear rare threats while downplaying risks that are far more real:

A whole industry has boomed around conquering the fear of flying, but while we down beta-blockers in coach, praying not to be one of the 48 average annual airline casualties, we typically give little thought to driving to the grocery store, even though there are more than 30,000 automobile fatalities each year.

One of Daley’s points seems especially valid in the current health care environment: We tend to gravitate toward that which confirms the optimistic beliefs we already hold.

For an example of this, look no further than screening for prostate cancer. The screening is common, it’s widely thought by the lay public and many doctors to be beneficial in catching prostate cancer in its early stages, and the belief is that it saves lives. But when you look closer, it turns out that, statistically speaking, the survival benefit isn’t particularly strong. Furthermore, aggressive screening has led to overtreatment, side effects and complications among men who could equally well have taken a watch-and-wait approach – or skipped the screening altogether.

When we’ve long held the belief that prostate cancer screening saves lives, however, it’s a hard pill to swallow that this isn’t the intervention we thought it was.

There’s sure to be a storm of controversy this week when the U.S. Preventive Services Task Force formally issues a new recommendation against routine annual prostate cancer screening for older men. In fact, the controversy has already begun with salvoes fired here, here and here. It’s all very reminiscent of a similar firestorm two years ago when the USPSTF recommended against routine mammograms for women in their 40s, saying there wasn’t enough evidence to support that routine screening saves lives and that mammograms for women in this age group should be made after weighing the pros and cons with their doctor.

Life would be easier if health care decisions were straightforward: Yes, this intervention will help; no, this prescription won’t help. Emotions, values and individual health history, coupled with the actual evidence (or lack thereof), make for a complicated tangle of factors to consider. We seem to slowly be coming to a realization, though, that overtreatment is as undesirable as undertreatment, and that some risks pay off while others may not. Making health-related decisions is a risky business that deserves to be approached with as much rationality as we can muster.

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