Fear and Control

By John Mandrola

Today’s column is from John Mandrola, Cardiologist, Electrophysiologist and Student of Medical History…..

John Mandrola, MD

In my first column for Sensible Medicine, I want to discuss the state of medical decisions.

My premise is that medical decision-making is ill, terribly ill.

The cause is in large part an excess of fear and a false sense of control. First let’s do fear then control.

Fear shreds the ability to make rational harm/benefit tradeoffs because it engages our fast-thinking reptilian brain. The vast majority of medical decisions benefit from slow-thinking.

In fact, one of the main ways a heart rhythm doctor helps people is the removal of fear.

How do we vanquish fear? It is not from priest-like proclamations to not worry. It is not from complex statistics. It is simple: we educate people about their condition. In most cases, the condition is benign. But when the condition isn’t benign, there are usually good treatments.

Once fear is removed from a situation, the slow-thinking brain can balance harms and benefits. For example, let’s say a person has a benign rapid heartbeat that comes and goes infrequently. Before fear had been extracted, this person would have easily signed on to an invasive procedure. “My heart feels like it is going to explode; I need this fixed.”

Once educated as to what this rapid heartbeat is, and that it is not dangerous, some decide to manage it without a procedure. Now a 1% procedural risk looks excessive for something that can be managed with simple maneuvers.

Fearful patients tilt the balance of power to the doctors. It’s not good medicine. Nor is it right. I despise the use of fear to influence decisions.

The other cause of poor medical decisions is a false sense of control. Doctors and patients alike underestimate the play of chance in health and disease.

A conversation a decade or so ago in the doctor’s lounge changed my approach to medicine. Now retired lung specialist Dr. John Lloyd was one of our hospital’s most respected physicians. He exuded calmness and wisdom and was one of those docs who wore a sport-jacket and tie even when he came to see patients late at night.

Lloyd had read a fiery editorial I had written about Vinay Prasad’s medical reversal paper. The fact that so many of our codified practices had been overturned when studied in trials led me to conclude that doctors needed to get far more serious about appraising evidence.  

Lloyd sat me down and said, “John, that was a nice column, but you mistake how much control doctors have over outcomes.” I’m like…”Dr Lloyd, I respect you tons, but recall that I am cardiologist; we control stuff!”

He smiled and told me the story of two patients he saw recently who had severe infection. Lloyd leaves the ICU in the evening thinking this extremely ill patient will be dead in the morning. But no, the patient responded to therapy and was sitting up eating breakfast the next day. Later in the week, Lloyd sees a patient with the same kind of infection, only this patient doesn’t appear as ill. He thinks the patient will respond nicely to the same therapy, but the next morning he learns that the patient had died.

Same pathogen, same treatment, opposite outcomes.

What Lloyd made me realize is that while doctors and patients strive to play the best probabilities, ultimately, we don’t have as much control as we think we do. I sort of understood this, but for some reason, I now felt moved by this “new” revelation.

Two examples:

We use anticoagulant drugs to prevent strokes in patients with atrial fibrillation who have risk factors, things like diabetes, high blood pressure and older age. The drugs also increase the risk of major bleeding.

When you look at studies of thousands of patients, the net benefit favors the drugs—on average. Let’s say the net benefit is 1-2% fewer strokes than major bleeds. I made up the numbers but the point is that while the average effect is beneficial, the vast majority of patients get the same outcome regardless of their choice, and some are harmed by the beneficial choice.

The take-home is that while we should help people make the best probabilistic choice, no one should lose their mind if a patient declines to take the guideline-directed net-beneficial medicine.

Another example is screening for one specific disease. Let’s take colon cancer screening in a person without a family history or predisposing risks. The medical establishment recommends screening older adults for colon cancer—and the preferred means is colonoscopy.

I won’t go into the exact data, but this extremely lucrative procedure with a small but finite chance of severe complications likely results in a small reduction in the chance from dying of colon cancer.

Yet colon cancer is but one of a gazillion ways of dying. A person could die of trauma, hundreds of other cancers, heart disease, neurologic disease, kidney disease, infection or a host of other things.

I remain intensely curious as to why people could think that a tiny reduction in the odds of dying from one disease changes your overall survival.

No one should mistake these words for nihilism. I love the practice of medicine. The job exudes meaning because we strive to help people. And we often do—with our words as much as our catheters and scans. We especially excel in helping those who are ill and asking for our help.

Medical decisions would be far better if there was less fear and less overconfidence in how much each decision controls outcomes.

These are major reasons why I write.