Buckle Up

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Lipitor can destroy your liver.

Back surgery can leave you paralyzed.

People who take Chantix might kill themselves.

You may never wake up from a simple surgery.

These statements are all true.  They also are very confusing to many of my patients when I am prescribing drugs or recommending surgery.  What should they do when they hear such bad things about drugs, surgeries, or procedures?  How much do they risk when they follow my advice?

It\’s a hard world out there, with the attorneys advertising on TV about drugs my patients have taken, with the websites devoted to the harms brought on by a drug or an immunization, with Dr. Oz and other seemingly smart people telling them things that are contrary to my advice, and with friends and neighbors who give dire warnings about the dangers of following my advice.  There are so many voices out there competing with mine, that I sometimes spend more time reassuring than I do anything else.  A doctor in our practice believes that Dr. Oz ought to issue a statement to doctors whenever he voices another controversial opinion as gospel fact so that we can be ready with our counter-arguments.

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What can doctors do?  We can\’t quiet the other voices that speak against us.  In truth, those voices have an important role in preventing us from becoming comfortable and dogmatic in our beliefs.  So how do I combat such a heavy current against our advice?

By talking about seat belts.

Seat belts can kill you, you know.  You can be trapped inside your car by your seat belt and not be able to get out before your car explodes.  It\’s not a fable; it can really happen.  You may be sealing your fate to die terribly every time you buckle your seat belt.

When I say this to my patients they instantly get what I am saying.  Sure, there is risk putting on a seat belt, but that is overwhelmed with the risk of not wearing it.  EMT\’s will tell you that they rarely unbuckle a dead person.

I love using illustrations like this.  I can, with a good illustration, explain a highly complex subject in very little time.  They give the patient something they understand as a basis on which to consider their options.  In the case of the seat belt, the analogy gives them perspective.  It shows them that the people who talk about the bad stuff aren\’t lying (seat belts really can kill), but they aren\’t considering the risk of not having the surgery, taking the medicine, or getting the procedure done (seat belts save lives).

There is the risk of over-simplifying something, or leading patients to believe something is lower risk than it really is.  That\’s why I always follow this by talking about how I feel the risk of taking the medicine compares with that of not taking it.  I don\’t argue against those who say Lipitor can destroy your liver, doing so would undermine my credibility because Lipitor can kill your liver; I just simply put that risk in perspective.  Analogies alone don\’t explain things, but they do take difficult to understand concepts and bring them into a world the patient understands.  From that point on, the explanation is much easier.

I used the analogy this morning explaining to a mother who was worried about the risk of ear tubes in her baby.  I explained that the risk of surgery (wearing the seat belt) was much less than the risk of antibiotic over-use (not wearing the seat belt).  She visibly relaxed when I said this.  I am not belittling her fear, I am just putting it in perspective.

I use seat belt analogies in other ways too.  Today someone told me that they never get flu shots and haven\’t ever gotten sick.  I told them that I could have never worn a seat belt in my life (which is almost 50 years) and I would still be alive talking to them.  I\’ve never gotten into a serious accident, so seat belts have been a complete waste of time, right?  The patient smiled when I said this.  No, I told him, I think it was a good idea to wear them and will continue to do so.  People who wear seat belts are more likely to be alive in a year than those who don\’t.  The exact same thing is true for high-risk people and flu shots.

He still didn\’t get one.

I also talk about the warning labels that seat belts would have if they had to list all of the ways you could be harmed by them.  Imagine a seat belt commercial done like a pharmaceutical ad: \”Seat belts could choke young children, could trap you in the car and kill you, could cause bruising to the shoulder, pinching to the fingers, lacerations, and abrasions.  Seat belts also could be used maliciously by older brothers to torture their younger sister.  Call your mechanic if you cannot unfasten your seat belt for more than four hours.\”

You get the picture.  So do my patients.

Buckle up.

10 thoughts on “Buckle Up”

  1. I know the plural of anecdote isn’t data, but I quit smoking while taking Chantix and I’m glad I did.  Nothing like sucking smoke into your lungs and feeling NO relief as you do it to show you just what a bad idea smoking really is.

  2. Helping people understand risk is tremendously difficult, and your analogy sounds like a good tool.   Information without appropriate context can cause oodles of problems.
    I would love to find the people who permitted direct-to-patient advertising of prescription drugs and lock them in a small room with a pack of angry badgers.  The latest one that drives me to fits of hysteria:  “If you’re a man over 40 and feeling ‘off your game’, don’t blame it on aging.  You may have a condition called low testosterone, or ‘low T’…”  which in the vast majority of cases IS CAUSED BY AGING, YOU IDIOTS!!!  There are certainly men who require testosterone supplementation for one reason or another, but that’s not who this commercial is aimed at and we all know it.  It’s aimed at guys like my 56-year-old husband who worries because he can’t do the same things he did when he was 20.  Increasing his testosterone levels will not make him able to do those things again, because he’s still not 20.  Grrrr…

    Sorry.  I’ll get off my soapbox now.  That’s *your* spot, Dr. Rob!  😉

  3. “The plural of anecdote isn’t data” — I love it!  I  intend to shamelessly steal that to use when trying to explain the concept of evidence-based medicine to clinicians.

  4. Ok, so I just don’t get this. I pay Dr. R for his advice. My experience is that he is rarely wrong. He actually usually has it nailed before I get finished telling him about it. The one and only time I ever asked Dr. R to consider something I’d heard somewhere else, it turned out badly and it was only thanks to Dr. R’s caution that the situation wasn’t disastrous.  So why after paying him for his very expert advice would I take Dr. Oz’s word for it, or my neighbor or especially my sister who thinks all doctors are quacks? She has never met Dr. R. That just doesn’t make any sense to me. 

  5.  Where were you 25 years ago? I unfortunately came of age just after the FDA (or whoever it was) decided that it was perfectly legal for psychiatric hospitals to advertise on TV.  Their ad campaigns were roughly similar to “Do you have a sullen teenager? Well, send them to Our Inpatient Hospital and we’ll fix them right up!”  For chrissake, who *doesn’t* have a sullen teenager to deal with at some point in their lives? My parents fortunately decided to spare me the indignity of inpatient “therapy”, but they still insisted I see a shrink, who put me in special education for two years.  I get that parents are busy.  I get there are days when the last thing a parent wants to do is try to find out *why* their teenager is “sullen”, and it’s much easier to just punish the behavior and ignore the underlying cause.  But, as I explained to the shrink, “…if I could talk to them (my parents), do you think I’d be sitting here right now?” I’m not saying that there aren’t good, valid reasons for a parent to send their child to an inpatient facility, or private counseling, if the need is really there.  But direct marketing campaigns make lazy or uncaring parents an easy mark for their claims.  After all, if the parent relies on the hospital to “fix” their “unfixable” child, the parent’s absolved of any responsibility, right?

  6. Great post.  I love how you help me identify clinical decision making tools I already use.
    I suspect we have a very different pt population.  A significant number of mine BELIEVE that seat belts are going to kill them and won’t wear them.  Let’s not even talk about flu shots or fluoride (and their precious bodily fluids…)

    Thanks,
    Sasha

  7. I had to have this convo last week and I suspect it will become much more common.The pt (who is a train wreck healthwise) said, “I like to educate myself so I’ve been reading up on testosterone and I’m thinking my fatigue may be caused by that so I want you to test my testosterone level.”

    Things I did not say (but wanted to):

    A) You read while you’re watching commercials on daytime tv?B) This is a sliding scale freaking clinic and I see that you have a pretty hefty balance already and you want me to spend another $50 on this?
    C) Instead of drawing this lab how about we just go find Suzanne Sommers and see if she’ll just find some T and inject it into your nuts?

    Complicating things is our clinic treats conditions that require testosterone and HAS it available for those pts with those conditions so other pts hear about it that way too.

    Anyway, thought I’d share 🙂

    feckalyn, FNP

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