Retirees, and anyone else caring for themselves or others, unfortunately have to work with an increasingly complex and dysfunctional health care system. Before retiring both as a full professor and as the founding director of the health informatics program at Dalhousie University, I was surprised when my students taught me that anyone who understands the basis of health care thinking can participate in their own care and solve many simple and complex problems. Here are some important lessons to keep in mind:
Purpose of care
People seek clinical advice because they want to improve how they feel, how they function and how long they are likely to live. Doctors might also make recommendations for screening tests to learn about risk factors for hidden disease and evidence of hidden treatable illnesses. Discuss with clinicians how you expect to benefit from their care.
Tests to detect and predict illness
Everyone who gets a medical test done should make sure that someone has seen the result (and that it has not been lost, misplaced or mishandled). They must also understand, with a clinician’s help, how to decide whether a test result is helpful or misleading. Not all tests are 100 per cent reliable. Some can give misleading results, leading to either a false alarm (a result suggesting an illness when the person is healthy) or a false reassurance (a result suggesting a sick person is healthy).
One reason that some forms of screening are controversial is that the number of misleading false positives could be unacceptably high and result in overtreatment or invasive investigations. Tests that mislead produce harms that are not outweighed by the benefit to some of earlier detection. When discussing test results ask how often the result might be misleading.
Making a diagnosis
Don’t give up. For some medical problems, such as fatigue, there are as many as 2,000 potential causes. When a doctor cannot explain your problem, it does not mean it is only in your head – it’s just that the doctor has not determined the reason (yet). If your doctor offers a mental health interpretation for your illness, say depression if you are feeling tired, ask how many rare and common conditions they considered and tested for, and which ones?
Treating a problem
Occasionally, a patient’s symptoms are very similar to benign conditions – a common cold or mild gastroenteritis for example, before recommending invasive tests or prescribing potentially harmful medicines, doctors will suggest to “watch and wait”, to see if the natural course of the problem gets better or worse on its own.
When more aggressive measures seem warranted, you and your clinician should have an understanding of the potential benefit or harm from the proposed treatment. It is important to consider the ideas of “all cause mortality” and “all cause morbidity.” We expect drugs to help the condition we have, but not increase the risk and harms by causing other problems. For some groups of patients, daily, low dose aspirin has a small effect on blood clotting and reduces the chances of heart attack or stroke. Unfortunately, the benefit is outweighed by an increase in serious and not so serious harm from gastrointestinal bleeding.
Other important ideas include “number needed to treat” and “number needed to harm.” How many people must be treated for one person to benefit and how many for one person to be harmed by the treatment. Understanding the importance of the benefits, and severity of the potential harm is also vital.
Finally, differentiating between absolute and relative risk reduction is also important. You can find additional information and a calculator on the British Medical Journal website. The underlying idea is that a drug that helps two people in a million is relatively better than one that benefits one person in a million. Yet, only one additional person in a million benefits if the drug is used. The relative benefit is the same for a drug that helps two people when five are treated compared with a drug that helps only one in five. However, in this case only five people must be treated for one to benefit. Absolute risk reduction is a more helpful measure so be cautious when a drug advertisement suggests that two or three times more people benefit from a drug compared to another drug or no treatment.
Each of us influences the thoughts, feelings and behaviour of the people around us. Except for drugs, the strategies we all use are the same as those used by mental health professionals. Thoughts, feelings and behaviour are influenced by the following:
- Words, how people speak with each other and what they discuss
- Rewards and punishments, incentives matter for children and adults
- Diet and exercise influence mood and how we function
- Drugs that treat medical conditions such as thyroid disease, or Addison’s disease
- Drug might influence thoughts, feelings and behavior even when a person has no detectable, laboratory confirmed, biologic abnormality.
- Drugs such as antidepressant medication that are meant to influence how people feel, and which have no measurable effect on abnormal biology.
- Self-prescribed easily accessible drugs such as alcohol and others, for example psychedelic agents.
Clinical care and science
Human relationships are at the heart of clinical care. Matching clinical advisors with patients who have similar values is important. Some important questions in clinical medicine remain controversial and clinicians might offer differing opinions where more than one approach might be acceptable. The more people understand the fundamental ideas in clinical care the better able they are to evaluate conflicting advice.
My colleague Dominic Covvey and I are completing a three-volume set of books that outline the important ideas I learned as a practicing clinician and academic and the ideas he developed as as an academic and founding director of the Canadian National Institute for health informatics. Expected date of publication is March 2024.
David Zitner is a professor emeritus-medicine at Dalhousie University.
The College and University Retirees Associations of Canada/Associations des retraités des universités et collèges du Canada (CURAC/ARUCC) is a not-for-profit federation of retiree associations at colleges and universities across Canada, operated by a volunteer board of directors. Further information, including a listing of member RAs, is available at www.curac.ca or from [email protected]. The two university professors emeriti who are co-directors for the CURAC/ARUCC University Affairs column are Carole-Lynne Le Navenec and Fred Fletcher.