July 15, 2009

Doctors are Gamblers

Doctors are Gamblers.

One of the questions in surveys that determine what sort of career in medicine you want asks:
How much ambiguity can you tolerate?
read: How much are you willing NOT to know? The answer is surprisingly telling.

I thought that as a physician in training, I would learn how to become more confident in my diagnosis when in practice, this is a very difficult thing to achieve. Especially in a brief visit where there are no clear labs or studies to elucidate the answer. Take a simple cold. A patient comes in with a sniffly nose, fatigue and a sore throat and asks: do I have strep? You can do a throat culture, but that will take time. You can do a rapid strep antigen test, but the test is not sensitive and you may get a false negative. Even for the most common conditions, there is a great deal about which we DO NOT know, nor can we ever know. We don't even have the tools to test for a lot of the different viruses that may cause a common cold... and why bother? It'll go away on its own with some fluids and rest.

Take another common concern: Doc, what are my chances of getting a heart attack?
We gamble on answers like this when we prescribe medications to reduce risk factors for coronary artery disease like high cholesterol (diet, exercise and statins,) and diabetes (diet, exercise, and metformin.) We risk stratify patients based on a collection of factors that have been shown to lead to increased risk of a heart attack in the future. The biggest study of this is the Framingham Heart Study. From a collection of statistics gathered from anamnesis (patient history) and labs, we can determine the 10 year risk of a patient for having a heart attack!

That's pretty powerful. But it is still just a Chance.
And how often do you really have a discussion like THIS with your doctor?!?
You're a 57 year old male. Your total cholesterol is 275. That's high because it's bigger than 200. Your HDL(good) cholesterol is only 35. That's low because it's less than 40. On top of that, you're still smoking and your systolic blood pressure(big number) is 150 despite being on medications!

You know, that means you have a greater than 30% chance of getting a heart attack or something similar in the next ten years. Think about that.

If you quit smoking and exercised to bring your blood pressure down to normal (120,) you could pull your risk down to 18%. That's still high but if we put you on a medication to lower your cholesterol and it was brought down to a normal level, we'd bring it down to 12%!

We can cut your risk in half with some simple changes. What do you think about that?

We gamble with people's lives. Some people live gluttonous self-indulged lifestyles and never have any health problems. Other people are health nuts but suffer from multiple ailments.

We don't know what hand people are dealt... but we can help stack the deck in their favor.

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