It may sound crazy, but many drugs, treatments and medical guidelines become common practice long before we know whether they work. Too often, we find out they don’t – and that they may even be harmful. (See The scary reality of medical U-turns)
So how can you make sure your treatment has been put to the test?
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Adam Cifu, professor of medicine at the University of Chicago and co-author of the book Ending Medical Reversal, says it starts with asking your doctor the right questions.
What questions do patients usually ask their doctors?
People tend to gravitate to what I think of as the second line questions, things like, how does this work? What are the side effects? Does my insurance cover this? These are all important, but definitely secondary to the most important question, which is, should I even be taking this treatment at all?
So what questions should we start with?
There are three.
- What data supports your recommendation?
The only way that we as doctors know something works – and the only way that patients will know – is if it’s supported by robust research, which is basically a good randomised controlled trial (RCT). Of course we often have to practice without robust RCT data, many clinical decisions have not been studied. But when decisions need to be made without the benefit of data, this should be discussed with patients.
- Have they tested for things that actually matter to me?
You’re not actually interested, for instance, in whether a drug helps your cholesterol, which is a stand-in for risk of heart attack or death. You’re interested in the actual endpoints, heart attack or death. That is, does this drug help you live longer, feel better, be happier?
- How likely is it that this treatment is going to help me?
In doctor-speak this is the “number needed to treat”. Put simply, this is the number of people who need to take a drug or undergo a treatment for one person to benefit. The best treatments I can offer usually work once in every 20 patients. So, taking a cholesterol medication after a heart attack, for every 20 people who take that drug for five years, one fewer person dies. You would be crazy not to take that medication. But if 10,000 people need to take it for one person to benefit, that might be something you pass on.
The nature of the treatment also matters. For someone who has been diagnosed with prostate cancer through screening, we have to treat about 30 people – treat cancer in about 30 people, which is not just taking a pill – to save a life.
Appointments are short, doctors are overworked and they might get defensive if you question them. How should patients start this conversation?
I like it when my patients take some ownership of the decision. For instance, saying, “This is important for me, I want to make sure I’m making the right decision” puts some of the pressure on the patient rather than the doctor.
Another thing is to acknowledge time constraints. Simply say, “I know you might not have time to discuss this now, but I would be happy to follow up at another appointment or by email or by phone.” Because many medical decisions you do not need to make on the day of the appointment. Of course, in an emergency situation you need to trust what the doctor says. But in a doctor’s office, where you’re trying to make a decision about the medication you’re going to take for the next five or 10 years, that can wait a month.
What should you do if your doctor won’t have the conversation – they get miffed and tell you, “I’ve been prescribing this to people for 20 years, it works”?
Find another doctor.
Our job is to have these discussions. I mean it. We have been trained to read and understand the literature and make these decisions. Some people may have the internet skills and background to be able to research things themselves, but that’s rare. Most of us are busy and have 20 other things on our minds. This is why you see a professional.
Are you worried this type of advice is going to make you unpopular with your colleagues?
[Laughs] Yeah, maybe.
