Many medical interventions are 50/50: Who informs the patient?

Many medical interventions are 50/50: Who informs the patient?

Lately, my virtual inbox in our electronic medical record has seen a surge in requests for prescriptions for the vaccine against herpes zoster, shingles. This has made me think a lot about our responsibility as physicians to inform patients about the evidence behind our recommendations – but who informs the patients when doctors are kept out of the loop or put under pressure to prescribe without seeing the patient?

What has happened is that our local Rite Aid Pharmacy started to give these shots, covered by many insurers, but still requiring a doctor’s prescription.

I cannot give the shots in my clinic, because as a Federally Qualified Health Center, we are reimbursed at a fixed rate. The shingles vaccine costs more for us to buy than we charge for an entire office visit. I used to have the discussion about the shot, and would give patients a prescription to take to the pharmacy if they wanted it.

The pharmacy can give the shot at a profit, because it is considered a medication, just like a bottle of Lipitor.

The new system creates a bit of a dilemma for me. I get a message through the pharmacy that the patient wants the shot, and I don’t have the opportunity to sit down and review the effectiveness, side effects and long-term efficacy according to the available evidence with the patient.

For example, the shingles vaccine only cuts the risk of getting shingles in half. This is about the same effectiveness as the flu vaccine, but far less than, say, the vaccine against smallpox, which has now been eradicated.

Most patients are very surprised to hear about the 50% efficacy when I catch up with them at some later date; so many health care interventions are portrayed as both completely effective and absolutely necessary.

I see my role as a primary care physician as a guide and resource for patients, who are bombarded with overly optimistic claims and recommendations by mass media, drug companies and retailers.

Many patients believe that since we can effectively cure some previously deadly diseases, like Hodgkin’s lymphoma, and control others, like AIDS, we probably have even better success rates when dealing with more ordinary diseases.

True, many conditions we see in primary care do go away – sore throats, coughs, sinus infections and rashes – but not necessarily thanks to our treatment, since they usually go away even without a visit to the doctor. No, sadly, a 50% success rate is considered very good for most of the interventions we do in primary care.

The same 50% effect is seen in many clinical scenarios, that are often misrepresented, even by doctors, as much more effective:

Lipitor, mentioned above, and all the other statin drugs, can reduce heart attack risk by at most 50%.

Tight blood pressure control in diabetics only reduces cardiovascular risk by 50%.

Quitting smoking only reduces heart disease risk by 50%. (And, no, these three interventions are not additive; nobody gets a 150% reduction in risk by doing all of them.)

Early detection and treatment of lung cancer can reduce mortality, but only by 50%.

Mammography screening, according to one recent study, reduces death rates from breast cancer by only 50%.

And the list goes on. Patients are encouraged to take shots or pills to protect themselves from bad diseases, but do they know how effective the intervention is, or how long it will last? In the case of shingles shots, nobody actually knows yet.

As if 50% success rates weren’t bad enough, there are other interventions that have an even lower likelihood of being helpful, for example taking antidepressants when you are depressed: 30-40% is the commonly cited success rate here. Yet, how many patients want only the pill and not also the counseling that can bring the success rate to 60%?

That is still a surer bet than having cardiac stenting or coronary bypass surgery in an effort to cut the risk of cardiac death. There is no convincing evidence that either of these common and costly interventions saves lives. They often improve quality of life, but most patients and many doctors believe they are essential, life-saving procedures in most instances.

Something as seemingly straightforward as surgery for a torn meniscus of the knee, if you are old enough to also have some arthritis, is no better than physical therapy in relieving pain and restoring function over a six month period.

Who else, but the primary care provider will have these discussions with patients? I don’t hear the cardiologists explaining the evidence impartially to patients, and how many orthopedists are that reluctant to do surgery? They make their living doing the procedures that patients assume are necessary.

We seem to be caught in two opposing currents. One is the idea of primary care providers directing and coordinating patients’ health care in patient centered medical homes, helping patients navigate today’s complex health systems. The other current is to give pharmacies, retail clinics and specialists who aren’t trained or experienced in whole-patient care direct access to patients or populations of patients and having primary care doctors only gathering and storing the information after the fact.

I worry about where the fragmentation in the second scenario could take us. Who will help patients see the big picture, and who will support them in making decisions that take their entire health status into account? In a world where 50% success is considered good, there are a lot of judgment calls. And the more you carve up the care of the patient, the more random those judgment calls will be.

50% success rate doesn’t mean a half cure for everyone; it means half the patients get the desired outcome and half don’t. If we think of it that way, it might be clearer what this is all about: It is about knowing the patient, and having the kind of relationship with them that supports and empowers them in choosing between many different fifty-fifty propositions, some of them conflicting and most of them changing very fast.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • Suzi Q 38

    Who informs the patient?
    You, of course.

    • Acountrydoctorwrites

      I don’t always have that opportunity in the fragmented system we have. Patients asking me to bless their shingles vaccine at the pharmacy are not here with me to discuss it. And remember, unless there is a face to face encounter, primary care doctors don’t get paid. We can’t both see a patient every fifteen minutes and make contact with patients who are not present in our office!

      • Suzi Q 38

        Both my husband and I have received the shingles vaccine. We have different PCPs.
        I made two separate appointments, ordered the vaccine through the local pharmacy, picked it up both times and then went to see each doctor, who gave us the shot.
        I am sure each doctor was able to bill the insurance company. I hope.

        • Trina K.

          Did your respective doctors discuss the pros and cons of buying and receiving the vaccine to you? If something goes wrong, are you going to blame your doctors or the shills who sold you on the idea that you needed that vaccine?

      • rtpinfla

        Completely agree patients do not look for our blessings. The TV commercial told them all they need to know. If you ask to come in and discuss it they will likely accuse you of trying to milk them for an office visit. If you try to tell a healthy 45 year old that they really don’t need the shot they will more than likely suspect the only reason you won’t call it in is because you don’t get paid for it. And after they hang up with you they will go down the street and find a “good” doctor that will happily call it in unquestioned.

        • Trina K.

          But why would a longtime patient trust an ad on TV more than they’d trust their family physician? This is not a snarky question, I really am curious. Is it because the patient-doctor bond has been broken down by provider fragmentation, and lots of people don’t have just the one family doctor anymore, so they’ve never built up that trust?

          TV ads try to sell me LOTS of things I don’t actually need. If they try to sell me a shingles vaccine but my family doctor explains that s/he doesn’t think it’s really in my best interests, why would I believe the TV ad rather than my doctor?

          • rtpinfla

            Crazy ain’t it? I think you hit the nail right on the head. I do have patients I’ve developed a good relationship with and can discuss these issues with them. The ones I see that never come back are usually the ones that come to me for a specific issue and asking for tests, meds, or whatever, inappropriately. They are very upset when I tell them they don’t really need X, Y, or Z even if I have a very clear and logical explanation. As I think about it those patients are probably a small percentage of my clinic but they definitely stick out since those visits tend to be rather stressful- I get called a lot of names and they usually storm out angry. I like to pride myself on making every patient happy so these visits are like a kick in the groin, frankly.
            However, advertising and the media in general is a very powerful tool. When my opinion goes against what a patient has seen from their neighbor, in advertisements, or scary stories about “hidden health threats” from Dr. Oz or the local news, it can be an uphill battle.

  • David Gelber MD

    One point that is not mentioned in your article is the rate of complications related to treatment. If a treatment is successful 50% of the time without dise effect or complication, then it is worthwhile. However, if that 50% success rate carries a 70% risk of complication, then the cure may be worse than the disease. However the complications and side effects may be minor, which leaves a lot of variables to consider.
    That is why there is such a thing as informed consent. We physicians explain the treatment alternatives, risks, benefits and, perhaps, make a recommendation. Ultimately, the patient must decide.

    • Acountrydoctorwrites

      Sometimes doctors don’t tell patients the whole story, for example about cardiac stents rarely reducing mortality.

      • Suzi Q 38

        You are so right.
        I have another patient community on the internet that have had these stents put in.
        They are rested, alert, and concerned about their futures.
        At the same time, they are wondering why they agreed to it at all.

        • querywoman

          Your aunt already had the strange quality of endurance that gave her longevity. I don’t blame her for refusing the surgery.

          • Suzi Q 38

            Thanks, neither do I.
            At 100, whatever she is doing is working for her.

  • querywoman

    Once upon a time just a few vaccines were given to children annually and the military on entrance. Now there are umpteen vaccines.
    I can’t get a flu shot due to an allergy. Had one once, and it blew up like a baseball. Last season’s flu vaccine was notoriously ineffective, I think it was said to have prevented only 9% of flu cases. I don’t know how they came to that.
    Vaccines are a tough call.

    Chicken pox, a form of herpes, is a childhood disease that usually builds immunity.

  • SarahJ89

    As long as we have a for-profit medical system patients will be cash cows for whatever entity owns the PCP’s practice. We will not be informed about side effects and efficacy as long as there’s money to be made. The quality of medical care in my area has plummeted now that all of the practices in our area have been bought up by two hospitals.

  • rtpinfla

    And to make matters worse, that 50% reduction is a relative risk reduction. When one looks the “numbers needed to treat”, the reduction actually is significantly smaller.
    For example, if 100 patients in a given clinic do not take a statin such as atorvastatin, about 3 of those patients will have a heart attack in the next 3-5 years. However, if you put all of them on atorvastatin, only 2 will have a heart attack in the next 3-5 years. The drug companies claim a 33% reduction in heart attacks which is technically true but also very misleading. The other 97 patients are taking an expensive drug for no real good reason except they think they are cutting their heart attack risk way down.

  • drjoekosterich

    A recent review in the Mayo Clinic proceedings showed only 40% of medical procedures and practices were useful (or at least more useful than what they replaced). Medicine is full of uncertainty. This has not been communicated properly.

    • Acountrydoctorwrites

      I agree. The idea that medicine is an absolute science is unfortunately promoted to such a degree that physicians are held responsible for things that are beyond their control. I am afraid the Quality movement is making medicine seem far simpler than it is, since “quality” is usually measured by how well physicians follow guidelines, rather than by outcomes data. Some may say we physicians created our own mess, but I don’t think that is fair. I do think we have a lot of work to do in making our patients, our employers and payors see some of the ambiguity of medicine.

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