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Friday Jul 29, 2016

Artful Communication of Evidence Can Overcome Anecdotal Fears

A 47-year-old woman came to see me recently with a complaint of new-onset intermittent headache. After taking her history and examining her, my assessment was that she had a tension headache caused by extra stress she had been experiencing during a difficult week. She had responded fairly well to acetaminophen and hydration, but the issue hadn't completely resolved. She lacked any alarm signs that would suggest a serious medical cause.

"My sister has a friend who developed a headache out of nowhere, and it was because of a large tumor," she told me. "I am so worried about cancer that I haven't been able to sleep for the last few days. I really think that I need an MRI or something to sort through this."

In my medical opinion, there was no reason to order imaging. This was most likely a benign headache that would resolve in short order by continuing what she already was doing and focusing on stress reduction. But this example brings up a question that we encounter nearly every day: How should we as physicians handle patients who use anecdotal evidence to jump to unlikely conclusions?

It is important to remember how we are trained to think as opposed to how the average layperson thinks. The woman who heard a story about brain cancer thought she might have the same diagnosis based on what she perceived as similar symptoms. From our perspective, the N of 1 for an unlikely outcome means almost nothing. But this is how many people tend to think about and approach problems -- anecdotally, through personal stories.

As physicians, we have been taught to consider population-based studies in our decision-making process. We look for sample size and power to ensure that enough people with the appropriate demographic and variable risks are included to ascertain a valid outcome. Oftentimes, even a study with a sample of thousands of people is not enough to draw a statistically reliable conclusion.

We also tend to think in a probabilistic manner. Based on the history and exam of my patient with a headache, I may assign roughly a 90 percent chance that this is a standard tension headache without any complications, and only about a 1 percent chance -- or less -- that a malignant mass is involved.

In such a case, the odds are strongly against anything serious, but at what point would you consider an MRI? What if you determined there was roughly a 5 percent chance of cancer? Is that enough to justify advanced imaging, or would the figure need to be higher? These are difficult questions and require patient input, as well as input from other physicians in some instances.

When we hear these anecdotal stories that involve one person, we are not too inclined to legitimize a patient's concern. But then we risk discounting the patient and possibly our relationship with him or her. The trick comes in properly communicating our thoughts to patients while keeping in mind their concerns spurred by their experience. Specifically stating that this is what we think and why tends to go a long way toward fostering understanding.

Yet as we all know, sometimes this isn't enough, and the patient continues to request a test or treatment that is not indicated and could even be harmful. This is obviously treacherous territory. A serious discussion about risks and benefits is needed to inform the patient about the wisdom of following evidenced-based recommendations. But even despite comprehensive patient education, compromise is sometimes needed to preserve the physician-patient relationship -- although it is ultimately our responsibility to avoid wasting resources and putting the patient in danger.  

Is there enough time in our brief visits to have such discussions? Not always, and that can lead to dissatisfaction for both patients and physicians and at times can even contribute to malpractice suits. Hopefully, newly recommended payment models based on value will help improve this problem, but that is yet to be determined.

One of the most crucial aspects of patient relationships is understanding the different ways in which we have been taught to think compared with how patients tend to think about medical problems. Awareness of and deference to these differences could improve both the care we provide and our relationships with patients.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11(twitter.com).

Posted at 03:00PM Jul 29, 2016 by Kyle Jones, M.D.

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