It's easy to forget one huge value of having that possibly-worthless health screening visit: A relationship of trust develops between the doctor and the patient so that when the patient becomes sick (which will happen), the patient has a trusted source to turn to. I can point to many lives I have personally saved due to this relationship.
This really captures the “healthy visit paradox” in primary care: the better we’ve made populations (and the lower the baseline event rates), the more our preventive wins become statistically real but individually unlikely, so NNT/NNV/NNS quietly explode.
I also appreciated the honesty about how EMR prompts + guideline momentum can turn shared decision-making into checkbox medicine, while the downstream harms (false positives, overdiagnosis, procedural cascades, anxiety, cost, clinician burnout) stay off the scoreboard. The Prevnar example is a perfect teaching case for why absolute risk + patient context should lead, not just relative risk.
The question you end with is the one we all need to wrestle with: where do we set the “chagrin threshold”, and how do we build systems that reward wise restraint as much as action, especially when profit and incentives push in the opposite direction?
Would love to see more of this framed as “precision prevention”: risk-stratify, name the tradeoffs, and spend the precious visit minutes on what actually moves the needle for most healthy people; sleep, activity, nutrition, mental health, and the handful of truly high-value screens/vaccines for their risk profile.
So, I feel the need to share my own "process." I believed I was in relatively good health after surviving colon cancer that was diagnosed approximately a year after I completed residency. I changed my entire lifestyle: stopped smoking, became vegetarian, ran 3-4 miles daily (several marathons), etc. Forward the clock to the present, and I read a study from the CDC regarding former smokers, recommending a chest CT for individuals my age, so my primary doc scheduled it. No lung lesions, but the final line of the report read: "severe stenosis of the cardiac arteries." Workup verified it was indeed severe, so I had CABG. Further, R carotid artery was >95% blocked, so a stent was placed there as well. I was totally asymptomatic for both conditions - several colleagues said "Maybe you were 'totally in denial.'" Maybe, but the angiograms suggest the diagnoses were absolutely correct. My previous primary care doc - in my opinion, and by selection - was probably the single best & skilled diagnostician I have ever met. She never picked up on anything. I have awoken in the middle of the night thinking about how close was I to disaster? So, the question, had she asked it, "How can I help you?" would have been pointless. What else preventatively could have been done? I have no clue. How far outside the box, if at all, did I lie? And was I just lucky? You tell me.
Most of the preventive screening practices urged upon primary care practitioners have some evidence behind them.
I should caution that a substantial number have very little at all. In the “no evidence” category are recommendations to “screen for” drug use or suicidal ideation. There was an actual RCT of screening for drug use, published in JAMA, showing it did no good and the US Preventive Services Task Force recommended it anyway.
There is considerable reason to use common sense and ask people who are having a visibly hard time “are you …(insert any number of things here)” but that isn’t screening. That is following up on a signal of trouble.
Among the preventive tasks that have actual evidence, several require carrying out the task for hundreds or even thousands of patients in order to benefit a single person, as Dr Cifu so rightly points out
It raises the question, and this is a bit controversial so bear with me:
Perhaps we should ask patients “how can I help you?” as opposed to telling them how we are expected to help them.
It doesn’t mean we would do whatever flows next. If the patient says “get me a 6-pack of Budweiser”, we can decline.
But it sets the stage for a very different notion of what the “care” is in “primary care”!
I understand the weight of innumerable quality measures on the primary care physician, but I also think NNT needs to be weighed against the severity of consequence of actual disease and risk of intervention. As an ID physician who sees numerous invasive pneumococcal infections per year (incl empyema, meningitis), complicated vzv infections (incl encephalitis, CN palsy), etc and the relative safety profile of vaccinations, I think it is invaluable to have these interventions at least offered and presented to the patient. Also, NNT looks at direct effect on individual but I think we can’t downplay the effect of herd immunity and protection of the most vulnerable within the community (exemplified by childhood pneumococcal vaccination to overall population).
There is so much that primary care physicians do, and finding a great one is a challenge. As a physician myself, I find it hard to track my own vaccinations and screening measures. There is just so much and life is chaotic, busy, and most people deprioritize their own personal health.
I can’t tell you how much I appreciate my own pcp to keep me on track. What she does for me may be routine, but it is invaluable to me. I truly believe that doctors do help healthy people by keeping them healthy.
2. If you're like me - was relatively healthy <50yo - you find out the platelets are <100k. Over a few months w/ follow up visits, including a heme-onc, d/t the out of range plts, you get a myelodysplastic syndrome (MDS), bone marrow failure diagnosis.
Assuming the patient is likely to be healthy enough for a bone marrow/stem cell transplant in 1yr or 8yrs, it might be worthwhile to freak out the patient. Given the Next Gen Sequencing technology and advances in MDS prognostics, the seriousness of the genetic mutations can help a person make plans for their next several years/life.
But maybe it's just better to discover the problem when the person can't walk 100 feet w/o severe SOB or nasty infections from neutropenia or strokes from low platelets? That's a real question - not a sarcastic poke. I don't know if it's worth the anxiety for most patients. I'm lucky, though.
I went to my primary care doctor for a flu shot one year. She was checking me over and asked “How long have you had this lump in your neck?” I hadn’t noticed a lump at all. She sent me for a biopsy of the lump on my thyroid, which led me to having an endocrinologist. As the lump grew over the next couple of years, it was decided to remove it and that’s when we learned it was cancer, a kind that couldn’t have been detected from the initial biopsy. So my healthy self was helped by my doctor… Unfortunately she has now switched to a concierge practice because insurance is apparently a nightmare for everyone to work with. But I can’t justify paying her as much as my deductible AND my deductible each year.
Maybe this story doesn’t even correlate with this post.. but I just think it’s hard to have health care and most of us in the US actually just have “sick care”.
Thank you - everyone should read this piece. What we’re facing is the aligned interest of 1) well meaning public health folks who have latched on the routine primary care medical visit to seek to achieve population health goals, 2) drug and device makers, consultants and medical specialists who gain from all the follow up care, whether false positive or not, and 3) politicians and the worried well who aren’t able to go beyond the popular press and simple takes on often-biased journal articles and don’t get the difference between absolute and relative risk reduction.
I am retired now but I was a PCP for 33 years and, like Adam, I needed to find a way to think about routine screening that made sense. As he rightly points out if you think about the likelihood that any individual patient will benefit from any particular screening modality or preventative intervention you would be hard-pressed to recommend them.
My strategy was to think of me and my panel as a team. And, over time, if we all did our part:
-Me making the correct age and gender-based recommendations,
-The patients making appropriate, informed decisions, then,
-As a group we would have less, fill in the blank: ______ (flu, CAD, colon CA etc.) than would have occurred if the whole group had not been getting thoughtful preventative care.
I can't say if the "PCP + panel as a team" idea worked. Patients entered and left my panel all the time so the panel part of "the team" was a concept not an assessable entity. Personally, I found the "team" idea helpful and it was something that I could share with individual patients when the occasion arose.
This post perfectly encapsulates the cognitive dissonance facing modern primary care. The focus on Number Needed to Treat (NNT) reveals a core problem: we're trapped in a maximalist, "disease eradication" paradigm, measuring success by the extreme rarity of preventing an event in an already low-risk, healthy population.
To find the line you seek, we must introduce two critical shifts in perspective:
1. Shifting the Metric to Health Span: The NNT framework incentivizes chasing tiny statistical risks. Instead of purely preventing a single rare disease endpoint, we should prioritize interventions that robustly improve quality of life, functional capacity, and mental well-being across the entire health span. A recommendation that significantly improves a patient's energy or sleep quality has a much lower "NNT for happiness" than an intervention that prevents a 1-in-10,000 pneumonia case. This reframing replaces statistical anxiety with tangible, immediate benefit.
2. The Ethics of Opportunity Cost: We must acknowledge the cost of 'doing the little things'—not just financial cost, but the cost to the physician's time and mental bandwidth. Every minute spent debating a low-yield vaccine recommendation is a minute not spent building rapport, assessing social determinants of health, or counseling on high-yield lifestyle changes (which often have an NNT of 5 to 10 for major endpoints). The physician's attention is the ultimate constrained resource. We must move past the fear of chagrin and demand guidelines that reflect the opportunity cost of intervention.
The solution isn't to become nihilists, but pragmatists guided by resilience. We must move from an impossible goal of preventing every bad thing (Unconstrained Vision) to empowering patients to live well and recover quickly when illness inevitably strikes (Constrained Vision).
Final Thought: If the overwhelming majority of preventative advice has an NNT over 100, what is the NNT for physician burnout caused by the administrative burden of chasing impossible perfection? This is the line we need to draw
It’s not just the interventions themselves that are problematic. You might have to administer vaccine to 500 people to prevent 1 case of X, meaning that 499 doses were, in effect, wasted/useless/ineffectual. The bigger problem is what this does to the health care system. A primary care provider could spend their entire day/week/month/year/practicing lifetime recommending, arranging, administering, interpreting, and following up on things with very high NNTs. In other words, they could spend the vast majority of their time doing stuff that benefits a vanishingly small number of people. Sure, they feel great when no kids in the practice get polio, but they feel much worse when somebody who quit smoking and took statins has a heart attack nonetheless. To make matters worse, the entire system is becoming geared to making doctors do the preventative stuff, no matter how high the NNT. You’ll be frowned upon if your smoker hasn’t been counselled to quit, your patient with borderline BP isn’t on meds, your 40 year old patient wasn’t pushed to have a mammogram, etc.
No wonder doctors are burning out! It’s a no win situation. You’re blamed for failures of process. As for outcomes, it’s hard to take credit for rare things not happening, and easy to take the blame for predictable things happening despite your best efforts. Much easier, but soul-destroying, to do what you’re told, regardless of the evidence as it applies to the patient in front of you, and regardless of their values and wishes.
And no wonder the health care system has become so expensive. If all this prevention is truly justifiable on the basis of diseases prevented, health status improved, and lives extended, we should be saving money like crazy!
Interesting article! When I turned 65 my physician offered me the pneumonia vaccine. He said it would not prevent me from getting pneumonia only from dying from pneumonia. I took it. Was he telling me the truth?
As a primary care physician who now does healthcare priorities research, I think this piece brings up important points but also spends too little time on another point: Screening and prevention is about managing a risk, not a disease. We should not be surprised that for most people, the intervention will have no positive benefit. What we want is to do things that have benefits compared to the costs of doing the activities. These are both monetary costs and costs of time and attention in the healthcare system as well as time and attention of the patient. I still think a lot of the activities you describe in this piece are overrated, and would once like to see a rigorous assessment of the claim "prevention is cheaper/more effective than treatment."
Care providers would do well to find out with each patient what is keeping him or her from getting up and moving. What are the deterrents? Aches and pains? Weight? Mental mood? Address these things and encourage movement. One baby step at a time. A lot might be helped with this approach. I am a 73-year-old female, non-medical background .
Stop prescribing poisonous statins, which inhibit movement by causing joint pain, increasing the likelihood of diabetes and more. Make me feel bad with your RX’s and watch how little I want to engage in physical movement.
Dr. Cifu, vaccines did not rid the world of any diseases. That's not me saying it. It's the CDC's own data. For ex. The death rate from measles had dropped by 99% before the first measles vaccine came out 1963. This trend was observed for all infectious diseases. It was clean water, healthy food, and better socioeconomic conditions. Again, that's the CDC's conclusions
Wait, what? How about smallpox (declared officially eliminated by the WHO in 1980)?
As for measles, the decline in mortality by 1963 (closer to 90% than 99%) due to improved nutrition and public health measures does not tell the whole story. Measles can cause significant morbidity, including subacute sclerosing panencephalitis, acute disseminated encephalomyelitis, as well as immune suppression and secondary infections. Preventing these sequelae is certainly beneficial. And here's a telling except from your second reference (Guyer et al): "The reductions in vaccine-preventable diseases, however, are impressive. In the early 1920s, diphtheria accounted for about 175,000 cases annually and pertussis for nearly 150,000 cases; measles accounted for about half a million annual cases before the introduction of vaccine in the 1960s. Deaths from these diseases have been virtually eliminated, as have deaths from Haemophilus influenzae, tetanus, and poliomyelitis." All vaccine-preventable illnesses should not be lumped together. Each is deserving of a nuanced discussion.
Love this. We need to talk about these numbers more than blindly telling patients they “have to do this or that.” It comes down to informed consent and a risk benefit discussion between doctor and patient. Part of the problem comes in when others try to get in that relationship instead of being a guide or offering information.
It's easy to forget one huge value of having that possibly-worthless health screening visit: A relationship of trust develops between the doctor and the patient so that when the patient becomes sick (which will happen), the patient has a trusted source to turn to. I can point to many lives I have personally saved due to this relationship.
This really captures the “healthy visit paradox” in primary care: the better we’ve made populations (and the lower the baseline event rates), the more our preventive wins become statistically real but individually unlikely, so NNT/NNV/NNS quietly explode.
I also appreciated the honesty about how EMR prompts + guideline momentum can turn shared decision-making into checkbox medicine, while the downstream harms (false positives, overdiagnosis, procedural cascades, anxiety, cost, clinician burnout) stay off the scoreboard. The Prevnar example is a perfect teaching case for why absolute risk + patient context should lead, not just relative risk.
The question you end with is the one we all need to wrestle with: where do we set the “chagrin threshold”, and how do we build systems that reward wise restraint as much as action, especially when profit and incentives push in the opposite direction?
Would love to see more of this framed as “precision prevention”: risk-stratify, name the tradeoffs, and spend the precious visit minutes on what actually moves the needle for most healthy people; sleep, activity, nutrition, mental health, and the handful of truly high-value screens/vaccines for their risk profile.
So, I feel the need to share my own "process." I believed I was in relatively good health after surviving colon cancer that was diagnosed approximately a year after I completed residency. I changed my entire lifestyle: stopped smoking, became vegetarian, ran 3-4 miles daily (several marathons), etc. Forward the clock to the present, and I read a study from the CDC regarding former smokers, recommending a chest CT for individuals my age, so my primary doc scheduled it. No lung lesions, but the final line of the report read: "severe stenosis of the cardiac arteries." Workup verified it was indeed severe, so I had CABG. Further, R carotid artery was >95% blocked, so a stent was placed there as well. I was totally asymptomatic for both conditions - several colleagues said "Maybe you were 'totally in denial.'" Maybe, but the angiograms suggest the diagnoses were absolutely correct. My previous primary care doc - in my opinion, and by selection - was probably the single best & skilled diagnostician I have ever met. She never picked up on anything. I have awoken in the middle of the night thinking about how close was I to disaster? So, the question, had she asked it, "How can I help you?" would have been pointless. What else preventatively could have been done? I have no clue. How far outside the box, if at all, did I lie? And was I just lucky? You tell me.
Most of the preventive screening practices urged upon primary care practitioners have some evidence behind them.
I should caution that a substantial number have very little at all. In the “no evidence” category are recommendations to “screen for” drug use or suicidal ideation. There was an actual RCT of screening for drug use, published in JAMA, showing it did no good and the US Preventive Services Task Force recommended it anyway.
There is considerable reason to use common sense and ask people who are having a visibly hard time “are you …(insert any number of things here)” but that isn’t screening. That is following up on a signal of trouble.
Among the preventive tasks that have actual evidence, several require carrying out the task for hundreds or even thousands of patients in order to benefit a single person, as Dr Cifu so rightly points out
It raises the question, and this is a bit controversial so bear with me:
Perhaps we should ask patients “how can I help you?” as opposed to telling them how we are expected to help them.
It doesn’t mean we would do whatever flows next. If the patient says “get me a 6-pack of Budweiser”, we can decline.
But it sets the stage for a very different notion of what the “care” is in “primary care”!
I understand the weight of innumerable quality measures on the primary care physician, but I also think NNT needs to be weighed against the severity of consequence of actual disease and risk of intervention. As an ID physician who sees numerous invasive pneumococcal infections per year (incl empyema, meningitis), complicated vzv infections (incl encephalitis, CN palsy), etc and the relative safety profile of vaccinations, I think it is invaluable to have these interventions at least offered and presented to the patient. Also, NNT looks at direct effect on individual but I think we can’t downplay the effect of herd immunity and protection of the most vulnerable within the community (exemplified by childhood pneumococcal vaccination to overall population).
There is so much that primary care physicians do, and finding a great one is a challenge. As a physician myself, I find it hard to track my own vaccinations and screening measures. There is just so much and life is chaotic, busy, and most people deprioritize their own personal health.
I can’t tell you how much I appreciate my own pcp to keep me on track. What she does for me may be routine, but it is invaluable to me. I truly believe that doctors do help healthy people by keeping them healthy.
Why not include a CBC w/ or w/o differential.
1. You get a baseline.
2. If you're like me - was relatively healthy <50yo - you find out the platelets are <100k. Over a few months w/ follow up visits, including a heme-onc, d/t the out of range plts, you get a myelodysplastic syndrome (MDS), bone marrow failure diagnosis.
Assuming the patient is likely to be healthy enough for a bone marrow/stem cell transplant in 1yr or 8yrs, it might be worthwhile to freak out the patient. Given the Next Gen Sequencing technology and advances in MDS prognostics, the seriousness of the genetic mutations can help a person make plans for their next several years/life.
But maybe it's just better to discover the problem when the person can't walk 100 feet w/o severe SOB or nasty infections from neutropenia or strokes from low platelets? That's a real question - not a sarcastic poke. I don't know if it's worth the anxiety for most patients. I'm lucky, though.
I went to my primary care doctor for a flu shot one year. She was checking me over and asked “How long have you had this lump in your neck?” I hadn’t noticed a lump at all. She sent me for a biopsy of the lump on my thyroid, which led me to having an endocrinologist. As the lump grew over the next couple of years, it was decided to remove it and that’s when we learned it was cancer, a kind that couldn’t have been detected from the initial biopsy. So my healthy self was helped by my doctor… Unfortunately she has now switched to a concierge practice because insurance is apparently a nightmare for everyone to work with. But I can’t justify paying her as much as my deductible AND my deductible each year.
Maybe this story doesn’t even correlate with this post.. but I just think it’s hard to have health care and most of us in the US actually just have “sick care”.
Thank you - everyone should read this piece. What we’re facing is the aligned interest of 1) well meaning public health folks who have latched on the routine primary care medical visit to seek to achieve population health goals, 2) drug and device makers, consultants and medical specialists who gain from all the follow up care, whether false positive or not, and 3) politicians and the worried well who aren’t able to go beyond the popular press and simple takes on often-biased journal articles and don’t get the difference between absolute and relative risk reduction.
I am retired now but I was a PCP for 33 years and, like Adam, I needed to find a way to think about routine screening that made sense. As he rightly points out if you think about the likelihood that any individual patient will benefit from any particular screening modality or preventative intervention you would be hard-pressed to recommend them.
My strategy was to think of me and my panel as a team. And, over time, if we all did our part:
-Me making the correct age and gender-based recommendations,
-The patients making appropriate, informed decisions, then,
-As a group we would have less, fill in the blank: ______ (flu, CAD, colon CA etc.) than would have occurred if the whole group had not been getting thoughtful preventative care.
I can't say if the "PCP + panel as a team" idea worked. Patients entered and left my panel all the time so the panel part of "the team" was a concept not an assessable entity. Personally, I found the "team" idea helpful and it was something that I could share with individual patients when the occasion arose.
This post perfectly encapsulates the cognitive dissonance facing modern primary care. The focus on Number Needed to Treat (NNT) reveals a core problem: we're trapped in a maximalist, "disease eradication" paradigm, measuring success by the extreme rarity of preventing an event in an already low-risk, healthy population.
To find the line you seek, we must introduce two critical shifts in perspective:
1. Shifting the Metric to Health Span: The NNT framework incentivizes chasing tiny statistical risks. Instead of purely preventing a single rare disease endpoint, we should prioritize interventions that robustly improve quality of life, functional capacity, and mental well-being across the entire health span. A recommendation that significantly improves a patient's energy or sleep quality has a much lower "NNT for happiness" than an intervention that prevents a 1-in-10,000 pneumonia case. This reframing replaces statistical anxiety with tangible, immediate benefit.
2. The Ethics of Opportunity Cost: We must acknowledge the cost of 'doing the little things'—not just financial cost, but the cost to the physician's time and mental bandwidth. Every minute spent debating a low-yield vaccine recommendation is a minute not spent building rapport, assessing social determinants of health, or counseling on high-yield lifestyle changes (which often have an NNT of 5 to 10 for major endpoints). The physician's attention is the ultimate constrained resource. We must move past the fear of chagrin and demand guidelines that reflect the opportunity cost of intervention.
The solution isn't to become nihilists, but pragmatists guided by resilience. We must move from an impossible goal of preventing every bad thing (Unconstrained Vision) to empowering patients to live well and recover quickly when illness inevitably strikes (Constrained Vision).
Final Thought: If the overwhelming majority of preventative advice has an NNT over 100, what is the NNT for physician burnout caused by the administrative burden of chasing impossible perfection? This is the line we need to draw
It’s not just the interventions themselves that are problematic. You might have to administer vaccine to 500 people to prevent 1 case of X, meaning that 499 doses were, in effect, wasted/useless/ineffectual. The bigger problem is what this does to the health care system. A primary care provider could spend their entire day/week/month/year/practicing lifetime recommending, arranging, administering, interpreting, and following up on things with very high NNTs. In other words, they could spend the vast majority of their time doing stuff that benefits a vanishingly small number of people. Sure, they feel great when no kids in the practice get polio, but they feel much worse when somebody who quit smoking and took statins has a heart attack nonetheless. To make matters worse, the entire system is becoming geared to making doctors do the preventative stuff, no matter how high the NNT. You’ll be frowned upon if your smoker hasn’t been counselled to quit, your patient with borderline BP isn’t on meds, your 40 year old patient wasn’t pushed to have a mammogram, etc.
No wonder doctors are burning out! It’s a no win situation. You’re blamed for failures of process. As for outcomes, it’s hard to take credit for rare things not happening, and easy to take the blame for predictable things happening despite your best efforts. Much easier, but soul-destroying, to do what you’re told, regardless of the evidence as it applies to the patient in front of you, and regardless of their values and wishes.
And no wonder the health care system has become so expensive. If all this prevention is truly justifiable on the basis of diseases prevented, health status improved, and lives extended, we should be saving money like crazy!
Interesting article! When I turned 65 my physician offered me the pneumonia vaccine. He said it would not prevent me from getting pneumonia only from dying from pneumonia. I took it. Was he telling me the truth?
As a primary care physician who now does healthcare priorities research, I think this piece brings up important points but also spends too little time on another point: Screening and prevention is about managing a risk, not a disease. We should not be surprised that for most people, the intervention will have no positive benefit. What we want is to do things that have benefits compared to the costs of doing the activities. These are both monetary costs and costs of time and attention in the healthcare system as well as time and attention of the patient. I still think a lot of the activities you describe in this piece are overrated, and would once like to see a rigorous assessment of the claim "prevention is cheaper/more effective than treatment."
Care providers would do well to find out with each patient what is keeping him or her from getting up and moving. What are the deterrents? Aches and pains? Weight? Mental mood? Address these things and encourage movement. One baby step at a time. A lot might be helped with this approach. I am a 73-year-old female, non-medical background .
Stop prescribing poisonous statins, which inhibit movement by causing joint pain, increasing the likelihood of diabetes and more. Make me feel bad with your RX’s and watch how little I want to engage in physical movement.
Dr. Cifu, vaccines did not rid the world of any diseases. That's not me saying it. It's the CDC's own data. For ex. The death rate from measles had dropped by 99% before the first measles vaccine came out 1963. This trend was observed for all infectious diseases. It was clean water, healthy food, and better socioeconomic conditions. Again, that's the CDC's conclusions
Here are the links:
https://ourworldindata.org/grapher/measles-cases-and-death-rate
https://www.researchgate.net/publication/12227539_Annual_Summary_of_Vital_Statistics_Trends_in_the_Health_of_Americans_During_the_20th_Century
Wait, what? How about smallpox (declared officially eliminated by the WHO in 1980)?
As for measles, the decline in mortality by 1963 (closer to 90% than 99%) due to improved nutrition and public health measures does not tell the whole story. Measles can cause significant morbidity, including subacute sclerosing panencephalitis, acute disseminated encephalomyelitis, as well as immune suppression and secondary infections. Preventing these sequelae is certainly beneficial. And here's a telling except from your second reference (Guyer et al): "The reductions in vaccine-preventable diseases, however, are impressive. In the early 1920s, diphtheria accounted for about 175,000 cases annually and pertussis for nearly 150,000 cases; measles accounted for about half a million annual cases before the introduction of vaccine in the 1960s. Deaths from these diseases have been virtually eliminated, as have deaths from Haemophilus influenzae, tetanus, and poliomyelitis." All vaccine-preventable illnesses should not be lumped together. Each is deserving of a nuanced discussion.
Love this. We need to talk about these numbers more than blindly telling patients they “have to do this or that.” It comes down to informed consent and a risk benefit discussion between doctor and patient. Part of the problem comes in when others try to get in that relationship instead of being a guide or offering information.