Context

Photo by Towfiqu barbhuiya on Unsplash

“Doc, I didn’t take the medication you gave me.  I read something that said it would destroy my liver.”

Sigh.  

These conversations are far too common…and they make me wonder: what are they thinking?  Do they really think I prescribed the drug with the evil intent of destroying their liver?  Do they think I am ignorant of the risks of drugs I prescribed for them?  Or do they think I’ve been duped by the pharmaceutical industry and am somehow not seeing the other side?   I can’t imagine someone would choose me as their doctor if any of these are true, so I’ve concluded that they just haven’t thought it out.

I’m not the kind of doc that minds being questioned; in fact, I actually prefer patients that don’t accept things without question.  I don’t take it personally when a person brings up issues of side effects, risk versus benefit, or expresses their fears about a treatment.  It’s my job to explain these issues and address these fears whenever I advise a treatment.  When folks make statements like this, they are usually just telling me that they are scared to take medications.  They feel the risk is too high, given what they’ve read or heard about the treatment I’m suggesting.

Doctor’s weren’t questioned like this in the past.  This is largely because we had information that others didn’t have access to.  We were the keepers of the “secret knowledge” of the body, of drugs, of disease.  Sure, they could go to the library and get a medical tome, but that was just too much work for most people to do, and so we’d just dispense our judgment based on this secret knowledge and tell them what they needed.  Patients were often given a prescription without an explanation (other than “doctor’s orders”).

This all changed with the advent of the internet.  Suddenly, all of our secret knowledge was no longer secret.  Suddenly patients  had access to all medical knowledge and information.  If someone had a symptom, they didn’t need to wait it the doctor’s office to see if it was a concern, they just googled it.  The desire to do so was compounded by the increasing inefficiency of and frustration with the healthcare system.  Doctors won’t answer most questions over the phone, and office visits take lots of time and cost lots of money, so why not ask “Dr. Google?”  I can’t blame people for doing this; I do the same thing when my car acts funny, or my dishwasher stops working.  

But anyone who’s gone to Dr. Google for advice quickly realizes that there’s a problem with the information they get: why does it so often point to scary diagnoses?

The reason for this is that, while the information gotten on the internet may be entirely true, it lacks something that is extremely important: context.  Dr. Google knows facts, but it doesn’t know your past history, your demographics, your family history, your previous problems.  It doesn’t know if you are in the midst of a pandemic, doesn’t know what your overall risk is, and doesn’t know what previous blood testing has shown.

Let me explain by using a commonly questioned treatment: “statin” drugs for lowering cholesterol.  I’ve often heard the question, “what do you think about statin drugs?”  Alternatively I’ve gotten “I’ve heard that those drugs are dangerous, doc.”  My answer to those question and objection is simple: I feel about statin drugs the same way I feel about appendectomies: they are good when you need them, but bad when you don’t need them.  I give them to people who should take them, and stope them on people who shouldn’t be taking them.  

How do I decide?  Context.  I don’t approach high cholesterol as a problem, but rather as risk factor.  A high LDL cholesterol is associated with an increased risk of heart disease.  Lowering cholesterol using a statin drug can lower that risk by as much as 35%.  A 65-year-old diabetic smoker with high cholesterol may have a 50% chance of serious heart problems in the next 10 years, so taking a statin can lower that risk to 32.5%.  In that case, taking a medication with a 3% risk of serious problems to get that risk reduction is a very good deal.  On the other hand, a 35-year-old who is in good shape, has no significant heart risk factors, but has the exact same cholesterol as the previous patient may have only a 1% chance of having a heart attack in the next 10-years.  Taking a cholesterol medication lowers that risk to 0.65%.  Clearly this is a bad trade-off, and I’d stop any statin the person was on.  (There are a number of scientifically verified tools that give an estimated cardiac risk based on risk factors available…on the internet).

Another example: testing for strep throat.  One would assume a positive strep test means you have strep, and a negative one means you don’t.  But consider these situations: first is a person who’s had a close contact with someone with strep.  They have a bright red throat with 102 degree fever, and have a fine red bumpy rash on their torso (“scarletina” rash, which is seen in people with streptococcal infections).  But their strep test comes back negative.  The second person is totally asymptomatic with no exposure at all, but has a positive strep test.  How do you interpret these?  The first I call a false-negative test and opt to treat, despite the negative test.  The second is a bit harder (why did I do the stupid test in the first place?), but I would at best say they might be an asymptomatic carrier, but probably not treat them without symptoms.  This is the same test, but I interpret the test results entirely based on, you guessed it, context.

So what’s the point?  Should people stay away from medical information on the internet?  Heck no.  But they should read it with caution, understanding that the information is given as general advice that may not apply to their situation.  Do not trust medical blanket statements (except for this one, I say with no irony).  Cousin Joe with strong opinions about back surgery doesn’t know the anatomy of your intervertebral discs, nor does he know the risk of  long-term neurological damage versus the risk of the surgery itself in your situation.   The person on YouTube who preaches about the danger of antibiotics doesn’t know the type of infection you have, and the risk of non-treatment.  

Let me end by acknowledging that the healthcare system has been a huge reason this problem exists.  Most docs don’t do a Framingham risk calculation for heart disease when prescribing medication.  There’s no time to take a detailed history, nor is there time to explain the nuance of the medical decision-making to the patient.  It’s easier just to give the prescription, order the test, or send the person to a specialist.  Context is impossible to know if the doctor doesn’t take time to figure out the context in the first place.  That’s why antibiotics are given when they could be avoided.  That’s why statin drugs are given unnecessarily.  Medicine is often too hard to be done in a 15 minute visit (with 10 of those minutes spent dealing with the medical record).  So people are left to fend for themselves, which is also unacceptable.

The doctor may know more about medicine than you do, but you know more about yourself than they do.  The best way to give good care is to have good communication going both ways.  Ask questions.  If your doc doesn’t let you do so, then find someone who will listen and explain.

The reason for this is that, while the information gotten on the internet may be entirely true, it lacks something that is extremely important: context.  Dr. Google knows facts, but it doesn’t know your past history, your demographics, your family history, your previous problems.  It doesn’t know if you are in the midst of a pandemic, doesn’t know what your overall risk is, and doesn’t know what previous blood testing has shown.

Let me explain by using a commonly questioned treatment: “statin” drugs for lowering cholesterol.  I’ve often heard the question, “what do you think about statin drugs?”  Alternatively I’ve gotten “I’ve heard that those drugs are dangerous, doc.”  My answer to those question and objection is simple: I feel about statin drugs the same way I feel about appendectomies: they are good when you need them, but bad when you don’t need them.  I give them to people who should take them, and stope them on people who shouldn’t be taking them.  

How do I decide?  Context.  I don’t approach high cholesterol as a problem, but rather as risk factor.  A high LDL cholesterol is associated with an increased risk of heart disease.  Lowering cholesterol using a statin drug can lower that risk by as much as 35%.  A 65-year-old diabetic smoker with high cholesterol may have a 50% chance of serious heart problems in the next 10 years, so taking a statin can lower that risk to 32.5%.  In that case, taking a medication with a 3% risk of serious problems to get that risk reduction is a very good deal.  On the other hand, a 35-year-old who is in good shape, has no significant heart risk factors, but has the exact same cholesterol as the previous patient may have only a 1% chance of having a heart attack in the next 10-years.  Taking a cholesterol medication lowers that risk to 0.65%.  Clearly this is a bad trade-off, and I’d stop any statin the person was on.  (There are a number of scientifically verified tools that give an estimated cardiac risk based on risk factors available…on the internet).

Another example: testing for strep throat.  One would assume a positive strep test means you have strep, and a negative one means you don’t.  But consider these situations: first is a person who’s had a close contact with someone with strep.  They have a bright red throat with 102 degree fever, and have a fine red bumpy rash on their torso (“scarletina” rash, which is seen in people with streptococcal infections).  But their strep test comes back negative.  The second person is totally asymptomatic with no exposure at all, but has a positive strep test.  How do you interpret these?  The first I call a false-negative test and opt to treat, despite the negative test.  The second is a bit harder (why did I do the stupid test in the first place?), but I would at best say they might be an asymptomatic carrier, but probably not treat them without symptoms.  This is the same test, but I interpret the test results entirely based on, you guessed it, context.

So what’s the point?  Should people stay away from medical information on the internet?  Heck no.  But they should read it with caution, understanding that the information is given as general advice that may not apply to their situation.  Do not trust medical blanket statements (except for this one, I say with no irony).  Cousin Joe with strong opinions about back surgery doesn’t know the anatomy of your intervertebral discs, nor does he know the risk of  long-term neurological damage versus the risk of the surgery itself in your situation.   The person on YouTube who preaches about the danger of antibiotics doesn’t know the type of infection you have, and the risk of non-treatment.  

Let me end by acknowledging that the healthcare system has been a huge reason this problem exists.  Most docs don’t do a Framingham risk calculation for heart disease when prescribing medication.  There’s no time to take a detailed history, nor is there time to explain the nuance of the medical decision-making to the patient.  It’s easier just to give the prescription, order the test, or send the person to a specialist.  Context is impossible to know if the doctor doesn’t take time to figure out the context in the first place.  That’s why antibiotics are given when they could be avoided.  That’s why statin drugs are given unnecessarily.  Medicine is often too hard to be done in a 15 minute visit (with 10 of those minutes spent dealing with the medical record).  So people are left to fend for themselves, which is also unacceptable.

The doctor may know more about medicine than you do, but you know more about yourself than they do.  The best way to give good care is to have good communication going both ways.  Ask questions.  If your doc doesn’t let you do so, then find someone who will listen and explain.

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