April
2005
Putting Yourself First
Just when we learned
there was plenty of flu vaccine to go around after all, came the startling
revelations from two
separate studies that it protects neither the elderly nor infants.
What could this mean?
It doesn’t mean
that the government was alarmist, or outright wrong, in urging infants
and the elderly,
for whom the flu can be most serious, to get
vaccinated. It just means that when best
information was pooled and analyzed, no evidence showed up that getting a
shot made any difference — in the long run. But if you were lucky enough
to get a shot this winter and did not get sick, all the research in the world
won’t
keep you from getting another shot next year. And if you took the vaccine
and had a bad reaction to it, all those studies are so much bird-cage liner.
Flu vaccine, hormone
replacement therapy, Vioxx versus Celebrex — all
these headline issues exemplify the difficult choices we are having to make
as science
gets more complicated, and more publicized. But realizing the full benefits
of medical research will depend on how we translate statistics about how
disease
and treatment works in large groups of
people enrolled in clinical trials into usable intelligence we can apply
to our individually unique circumstances.
The difficulty in understanding
risk is complicated by the terms used to describe it. What would you make
of a news report that taking hormone replacement
therapy
led to “a 41 percent higher incidence of strokes?” What would you
make of it if you knew that the “higher incidence” meant only 8 women
out of 10,000 over a year’s time would have
a stroke?
It is
easy to see how the wrong choices can be made. Mix the inherent complexity
of risk statistics
with the
distortions in their presentation and our distaste for the underlying message
that nothing is
certain, and it becomes easy to see the problem. Equally dire, this pile
of information — a
virtual Tower of Babel — can easily lead to making no decision at
all.
It is hard for the
average primary care doctor, let alone her patients, to keep in mind the
two things that make it hard to use risk statistics to make
personal
decisions. First, that the course of any disease, while predictable in
a large group of people, is less predictable in an individual. Second,
and
even more
frightening, any treatment is effective in only a fraction of the people
using it. This is deeply unsettling.
As a result, we often
don’t really understand the risk our condition poses,
our options to reduce it and the long- and short-term trade-offs each option
entails. Really, risk is a number that to be meaningful must include not only
information about possible outcomes but also an individual’s values
and preferences.
A doctor can describe alternative
treatments, can talk about the chances of producing a given outcome and
can provide details about the side effects that have been observed in others.
But only one person can decide what each choice would mean to you.
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