Buckle Up

Rob Lamberts, MDLipitor can destroy your liver.

Back surgery can leave you paralyzed.

People who take Chantix might kill themselves.

You may never wake up from a simple surgery.

These statements are all true.  They also are very confusing to many of my patients when I am prescribing drugs or recommending surgery.  What should they do when they hear such bad things about drugs, surgeries, or procedures?  How much do they risk when they follow my advice?

It’s a hard world out there, with the attorneys advertising on TV about drugs my patients have taken, with the websites devoted to the harms brought on by a drug or an immunization, with Dr. Oz and other seemingly smart people telling them things that are contrary to my advice, and with friends and neighbors who give dire warnings about the dangers of following my advice.

There are so many voices out there competing with mine, that I sometimes spend more time reassuring than I do anything else.  A doctor in our practice believes that Dr. Oz ought to issue a statement to doctors whenever he voices another controversial opinion as gospel fact so that we can be ready with our counter-arguments.

What can doctors do?  We can’t quiet the other voices that speak against us.  In truth, those voices have an important role in preventing us from becoming comfortable and dogmatic in our beliefs.  So how do I combat such a heavy current against our advice?

By talking about seat belts.

Seat belts can kill you, you know.  You can be trapped inside your car by your seat belt and not be able to get out before your car explodes.  It’s not a fable; it can really happen.

You may be sealing your fate to die terribly every time you buckle your seat belt.

When I say this to my patients they instantly get what I am saying.  Sure, there is risk putting on a seat belt, but that is overwhelmed with the risk of not wearing it.  EMT’s will tell you that they rarely unbuckle a dead person.

I love using illustrations like this.  I can, with a good illustration, explain a highly complex subject in very little time.  They give the patient something they understand as a basis on which to consider their options.  In the case of the seat belt, the analogy gives them perspective.  It shows them that the people who talk about the bad stuff aren’t lying (seat belts really can kill), but they aren’t considering the risk of not having the surgery, taking the medicine, or getting the procedure done (seat belts save lives).

There is the risk of over-simplifying something, or leading patients to believe something is lower risk than it really is.  That’s why I always follow this by talking about how I feel the risk of taking the medicine compares with that of not taking it.  I don’t argue against those who say Lipitor can destroy your liver, doing so would undermine my credibility because Lipitor can kill your liver; I just simply put that risk in perspective.  Analogies alone don’t explain things, but they do take difficult to understand concepts and bring them into a world the patient understands.  From that point on, the explanation is much easier.

I used the analogy this morning explaining to a mother who was worried about the risk of ear tubes in her baby.  I explained that the risk of surgery (wearing the seat belt) was much less than the risk of antibiotic over-use (not wearing the seat belt).  She visibly relaxed when I said this.  I am not belittling her fear, I am just putting it in perspective.

I use seat belt analogies in other ways too.  Today someone told me that they never get flu shots and haven’t ever gotten sick.  I told them that I could have never worn a seat belt in my life (which is almost 50 years) and I would still be alive talking to them.  I’ve never gotten into a serious accident, so seat belts have been a complete waste of time, right?  The patient smiled when I said this.  No, I told him, I think it was a good idea to wear them and will continue to do so.  People who wear seat belts are more likely to be alive in a year than those who don’t.  The exact same thing is true for high-risk people and flu shots.

He still didn’t get one.

I also talk about the warning labels that seat belts would have if they had to list all of the ways you could be harmed by them.  Imagine a seat belt commercial done like a pharmaceutical ad: “Seat belts could choke young children, could trap you in the car and kill you, could cause bruising to the shoulder, pinching to the fingers, lacerations, and abrasions.  Seat belts also could be used maliciously by older brothers to torture their younger sister.  Call your mechanic if you cannot unfasten your seat belt for more than four hours.”

You get the picture.  So do my patients.

Buckle up.

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6 replies »

  1. I love how you put things in perspective to your patients. A friend of mine died from the flu about 5 years ago now. He was only 56, didn’t think he needed a flu shot he never got the flu.

  2. Life is about risks. Every day we make decisions that involve weighing the risks of one choice vs the other. Do I buckle up for that 10 minute trip to the grocery store? Do I get that funny mole checked out? Do I let my kid go on that camping trip with the school? Do I get the flu shot?

    We gather data/info to help us make choices-if the info is clear, in the seat belt example, we may well make the statistically correct choice. When it is not or when we don’t have the capability of processing the info in a meaningful way, we may make a different decision. Get your flu shot because “I said so” is about as good as “Eat your broccoli because I said so.” The Art of Medicine is, in part, about helping people get to the right decisions–the one that makes sense for them personally–and that is where good communication comes in. Buckle Up illustrates this point very well. Thanks Rob Lambert.

  3. To take a page from the field of finance, the problem here is about Black Swans and Complexity. Understanding risk, data, probability, statistics, and choice – whether in personal health or investing – is challenging on a good day. It’s hard for people to take in a constant shifting mass of information and to weigh risks and benefits.

    When it comes to money or health, there’s so much emotion and important variables at stake, it’s even harder. Most people don’t want lots of information or deep statistical analysis. They just want to be told what to do, by the experts that they trust.

    As people in politics understand (or are taught by their campaign managers and media consultants after the first time they give some erudite analysis of a topic), people need information in pieces that they can digest. I don’t always agree with Dr Oz or the sound bites that the media puts out, but I understand part of their goal. Give people a decision that they can walk away with so they know what to do.

    The second issue is about what Nassem Taleb calls black swans. These are the rare financial events (like the unlikelihood of finding a swan that is black) that occur extremely infrequently, but when they do, take the system out (think the mortgage crisis).

    The flu shot is a great example of this in a discussion of individual or population health. Most people will benefit. It will save lives and be a great vaccine. But a very small percentage of the population may develop Guillain Barre’s syndrome, a debilitating paralytic neurologic condition. I remember a friend who was in medical school and developed GB. He became paralyzed, was on a ventilator and even when he improved a little, never recovered his professional career. I don’t think he developed GB from the flu vaccine, but it registered in my memory enough that it gave me significant pause before I was willing to take the vaccine. But I did eventually, because I thought about the population statistics – just like seat belts, yes, they can kill. But most of the time they don’t and even help. And that was the risk that I had to decide I was willing to take.

  4. Great analogy, especially when referring to flu shots! I have been frustrated with the typical response for years and now will start using this analogy myself.

  5. Nice.

    Trail lawyers say “He with the Best Story WINS!”

    Simon Blackburn (‘Being Good,” “Think”) notes that we don’t just have our abstract beliefs, we have our STORIES, which convey and cement them.

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