UNCERTAIN

If we make the FOCUS of health care I would suggest that we be careful in regulating or making explicit expectations for it. A few DECISIONS that we know FOR SURE for nearly everyone could be appropriate to require, but most DECISIONS, no matter how likely they may seem to be desirable, if we do not know FOR SURE, we may be better off FOCUSing on how to help people make DECISIONS and let those most directly involved make the DECISIONS.

I wrote previously on UNCERTAINTY and much of that post is relevant to the discussion on health care DECISION-making. We are UNCERTAIN about most of the important factors that inform health care decision-making.

Let’s say we believe taking a statin will reduce mortality by a relative 25% (1 in 4 people who would have died) based on previously published evidence, and our patient has a 4% mortality expected over the next 10 years. We may expect for our patient that taking a statin will reduce mortality by an absolute 1% (1 in 100 chance, or 1 life saved for every 100 people like this patient who take a statin for 10 years).

In this scenario, to some degree we are:

·       UNCERTAIN if statins reduce mortality by a relative 25% across similar populations – How certain are we of the validity of the previously published evidence? Even if highly certain, do we know FOR SURE?

·       UNCERTAIN if that relative risk reduction applies to the patient before us – How certain are we of the applicability of the previously published evidence to this specific patient?

·       UNCERTAIN if this patient’s expected mortality is 4%

·       UNCERTAIN if this patient would be the 1 in 100 having the benefit, one of the 3 in 100 dying regardless of medication use, or one of the 96 in 100 who live, even if all the other concepts were known FOR SURE.

·       UNCERTAIN how this one factor relates to all the other factors considered when making a DECISION whether or not to take a statin

So what is the best approach to convey such UNCERTAINTY to a patient to support well-informed shared decision-making?   Discussing all of the above sounds overly academic, complicated and would make me think patients would seek someone else’s advice – the doctor is so UNCERTAIN do they understand anything? But on the other hand presenting it with no UNCERTAINTY (“This medicine will save your life”) is dishonest and oversimplifying.

For health care professionals more and more people are using “quality of evidence” ratings (High, Moderate, Low, or Very low quality of evidence) to understand how certain we are in the results of research?  I wonder if such ratings for different concepts would be helpful for patients to see directly if it could be presented simply enough to avoid confusion.