I've noticed that doctors like to use the phrase, "I've never seen [insert outcome here]" to try to convince their patients that something is OK (or not OK).
My mom had surgery on Monday (everything's OK, no big deal) and the physician was going through the consent form and came to nerve injury. The official risk is 1%, but "I've never seen it happen," he said.
Mountain Mama the same day posted this (really good) essay regarding the seemingly confusing decision parents face regarding vaccination, in which a physician is discussing the pros and cons of influenza vaccination during pregnancy with a patient. The physician tells the patient, "if you do get [the flu], you should know that pregnant women have a higher rate of complications than the general population," then continues, "But I've never, in all my years of practice, had to hospitalize a pregnant patient for the flu."
Here's my issue with that statement.
-On average, according to the CDC, every year more than 200,000 people are hospitalized in the United States for conditions due to or related to influenza. The average age-specific hospitalization number for people ages 5-49 is 47,745 people.
-According to the National Center for Health Statistics, the pregnancy rate in 1999 was 102 per 1,000 women ages 15-44 (with a total of 6.27 million pregnancies in 1999)
-According to census data, there were 270.5 million people in the U.S. in 1998, and 138.2 million or 51.2% of them were women. Of the women, 60.1 million were ages 15-44.
So assuming that the influenza attack rate does not favor men over women or vice versa (a fair assumption, I think, but let me know if you disagree), and acknowledging that the influenza hospitalization stat isn't perfect since it was for people ages 5-49 while the pregnancy data was for women ages 15-44, we can figure that in 1999 about 51.2% of people ages 5-49 who were hospitalized for influenza were female, for a total of 24,445, and 6 million women ages 15-44 were pregnant.
So 0.4% of pregnant women in 1999 were hospitalized for influenza, which is 4 of every 1,000 pregnant women. I couldn't tell you off the top of my head the pregnancy rate in an average Ob/Gyn office's patient census, but I'm going to presume there are fewer than 1,000 pregnant women in the average office during a flu season. Statistically, though, one of those 4 hospitalized women is going to end up in that doctor's practice at some point, and the only way to prevent it would be to get the flu shot. No solace regarding future potential influenza infection should be found in the phrase, "I've never had a patient who needed to be hospitalized" when the doctor has no control over what determines whether a patient needs to be hospitalized. Statistically, if I were planning on refusing the flu shot, I would feel better if one of her patients HAD needed to have been hospitalized already! Since none of her patients have been one of those four-per-thousand yet, I'd be clamoring for the vaccination so as to not become her one statistical patient.
And while I also found my mom's surgeon's use of the phrase, "I've never seen it happen" annoying and falsely reassuring, it's a little different, because he IS able to control, to a larger extent, whether the negative outcome occurs. A good surgeon is aware of the risk of nerve damage and knows how to avoid the nerve, and is able to control a lot of the factors that go into whether a surgical infection occurs. So a good question to ask a surgeon when you are told what the infection risk for your procedure is, is "What is your infection rate?"
One of the things we learned back in our pre-clinical years was that people like information conveyed to them in different ways. Some people like numbers and statistics, if broken down to simple, conversational terms. Others hate them and find solace in phrases like, "unlikely to happen." You can't really tell ahead of time which patients are going to be what kind of people, but I know what I like and how I like to communicate. Cold, hard facts.
So I vow not to use the phrase, "I've never seen it happen." Because there are already plenty of things that I HAVE seen happen that other med students havne't. Are my patients more or less likely to suffer the same outcomes just because I saw it happen before? I don't think so. That's why the statistics are tabulated, so that we do know what affects illnesses and outcomes. Unless it's something the physician is directly responsible for, personal experience shouldn't play a role in recommendations, in my opinion.
Thoughts?
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8 comments:
I have a question about the flu vaccine: I've never gotten one. And in the past 10 years, I've gotten the flu twice. Is that a low number of occurrences, or about average? And if it is low, am I still an idiot for not getting the flu vaccine? I guess I'm asking if it's just dumb luck that I've not gotten the flu in a while or if my immunity is generally higher.
I'm not opposed to having the vaccine, btw. I am pro-vaccine. I've just been lazy about it.
Also, I applaud your decision to stick with numbers and facts. I know that people who are ill and possibly in denial about their illness want to hear things like, "I've never seen that" or "It doesn't happen very often," but I think it's the doctor's responsibility to paint an accurate picture of likely outcomes. It may not be what the patient wants to hear, but on one wants to hear bad news about their health. It's important for doctors to do everything they can do to help their patients understand the reality of the situation.
You're at low risk for getting the flu, Alissa, and for giving it to people who would get very sick if they got it. You're not super young (sorry!) or super old (yay!), are in general good health, aren't pregnant, and aren't taking care of small children or old people on a regular basis. If you have asthma you might want to consider getting the flu shot, since that is a comorbidity that makes having the flu worse. Otherwise, it would be totally up to you whether to get the flu shot. This year's flu shot sucked in terms of targeting the prevailing flu strains, so it's never a 100% guarantee. But if you've had the flu before, and you think you could stick it out through another round of 3-4 days of lying in bed with fever and muscle pain and generally wanting to die, then you could continue being lazy :) If you truly had flu those two times (like, tested positive on a nasal swab), then that's probably a low-to-average rate, especially considering you don't get the flu shot. So the reason you or someone like you would consider getting the flu shot would be to avoid missing work and spending those few days in bed feeling so miserable. The very old, young, sick, and pregnant are recommended to get the flu shot because if they do get it they are not only going to feel miserable, but are more likely to need to be hospitalized due to complications.
I think I'll get one next year because of working in a school. I think I had flu a few weeks ago (worked through it) but it developed into bronchitis and sinusitis and a lingering cough. I was just lazy, too, since they stopped giving them at my school.
"Statistically, if I were planning on refusing the flu shot, I would feel better if one of her patients HAD needed to have been hospitalized already! Since none of her patients have been one of those four-per-thousand yet, I'd be clamoring for the vaccination so as to not become her one statistical patient."
You might feel that way, but statistics would have nothing to do with it. Your individual likelihood is still 1 in 250 regardless of the previous patient outcomes. Or do I misunderstand something about disease statistics?
Nope, adspar, you're absolutely correct. I would be falsely reassured, indeed.
Here's something I wonder about: how frequently do you tend to have cold hard numbers that you feel are accurate? A lot of times if I ask for that kind of detail (because I'm a numbers person too), I get a kind of, "Eh, chances are pretty slim," or, "You might find that." That kind of thing. So I wonder, with what level of regularity do you actually have a statistic in your brain for a given situation?
Right now, never. But every 6 weeks I'm expected to change everything I know about everything, so I don't have time to commit any statistics to memory. However, I have seen physicians do this within the context of their own fields. So once I stop learning hodge-podge stuff, I believe I will start committing specific statistics to memory.
However, even now when patients ask me, I always look numbers up for them. Sometimes it means calling them back at home, but that's not that hard to do.
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