A Free App for Deciding About Aspirin

Once you hit 40 or so, you may hear that you should be taking a low dose (75 to 81 mg) of aspirin to help prevent cardiovascular disease (CVD) and colorectal cancer (CRC).  It can be tempting to go for it because it’s cheap and prevention seems a whole lot better than treatment, right?

Well, like so much in medicine, it’s complicated. But there’s a new free app that should  help you may a more informed decision, and it will certainly prepare you to ask your physician or nurse practitioner better questions about the pros and cons specifically for you.

Even if you’re not that interested in the question of whether you should take low-dose aspirin or not, checking out this app is a good exercise. Most of all, it will help teach you more about the delicate balance that has to be part of almost every decision that you make or that is made for you in health care. 

This app is also a great step toward making the decision making process in medicine highly personalized to the individual patient. It helps you identify the specific factors, based on the latest research, that weigh into the decision you and your physician are about to make.

First, some quick background. The U.S. Preventive Services Task Force published a paper in April, 2016 in the Annals of Internal Medicine that recommends taking low-dose aspirin to prevent CVD and CRC if you’re 50 to 59 and have a 10% or greater risk of developing cardiovascular disease in the next 10 years, and aren’t at increased risk for bleeding, among other factors. If you’re 60 to 69, the task force says it’s really an individual decision and the pros and cons are a close call, so they say it depends on whether you place a higher value on the potential benefits or want to avoid potential harms. If you’re 70 or greater, they say there isn’t enough evidence to advise you.

Using the App

So how do you digest all that and make a decision that’s right for you? Two cardiovascular physicians who also specialize in public health from Brigham and Women’s Hospital in Boston and a computer programmer who develops medical apps came together to create the Aspirin-Guide app, available free at the Apple store.

As one of the app developers told a reporter at Science News, “We developed the Aspirin-Guide app because we realized that weighing the risks and benefits of aspirin for individuals who have not had a heart attack or stroke is a complex process. The new mobile app enables individualized benefit to risk assessment in a matter of seconds while the patient is with the physician,” said Samia Mora, MD.

Questions You’ll Be Asked

Technically, the app is designed to help physicians decide, but it will be easy for you to use if you know a few things about yourself:

  • Do you have a history of having had a heart attack, chest pain, bypass surgery or a heart stent, a stroke from a blockage in an artery, or peripheral vascular disease?
  • Are you hyper-sensitive to aspirin, had bleeding in your gastro-intestinal system, unexplained bleeding, have sever kidney or liver disease, or are taking a blood thinner (anticoagulant or anti-platelet)?
  • Your age, race and gender (easiest questions in the app)
  • Are you a smoker?
  • Do you take medications to lower your blood pressure?
  • What is your systolic blood pressure (the “top” number, or the 120 in 120/80)
  • Do you have diabetes?
  • Do you take a cholesterol-lowering medication?
  • What is your total cholesterol level (something like 200 mg/dl, for example)
  • What is your HDL cholesterol level (something like 50 mg/dl, for example)
  • Do you have atrial fibrillation?
  • Do you take an anticoagulant or antiplatlet drug (commonly called blood thinners)
  • Have you had a (peptic) ulcer?
  • Have you had upper gastrointestinal pain or dyspepsia (painful, difficult, or disturbed digestion, possibly also with symptoms such as nausea and vomiting, and heartburn)
  • Do you use NSAID drugs (such as Advil , Aleve, or aspirin, for example) at least 2 to 3 times a week?
  • Do you take Prednisone or other oral corticosteroids (not creams).

Digesting the Guidance

After being led step by step through these questions, you are given guidance. Mine, for example, said “Do not advise aspirin.” Yours could be different. But then the app tells you more specifics, explaining whether the harm of taking a low-dose daily aspirin might be greater than the potential benefit.

And then, you can push the button and email  the results to yourself, or even to your doctor. Using this app makes me eager to see more tools that will give a wider window for each of us into how to weigh the pros and cons of the many decisions we make about our health every day.

 

 

 

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Getting an Appointment

It’s getting harder than ever to get a healthcare appointment, whether it’s for your primary care doctor or for a specialist. I have a friend who was recently told he would have to wait weeks to see an oncologist after his pulmonologist discovered he had lung cancer.

I know someone else who was the victim of a merger of two infusion centers. He had been on a routine of getting blood drawn one week and then being scheduled to receive I.V. chemotherapy the next. Right after the merger, the doctors and staff were so overloaded that the office had no open appointments and his treatment regime was dangerously put on hold.

A study by Merritt Hawkins in 2014 looked at five medical specialties — dermatology, orthopedics, obstetrics and gynecology, cardiology, and family practice — in different parts of the U.S. They found the average cumulative wait time to see a physician for all five specialties was 19 days. The longest wait time to see a physician was 256 days for a dermatologist appointment in Minneapolis. Boston had the highest cumulative average wait time to see a physician: 45 days.

It’s maddening. Some experts say the challenge of getting seen is only going to get worse as baby boomers age, more people get access to health care and the physician shortage continues. And these long wait times to get an appointment aren’t just for your first visit with a new specialist. Even so-called “established patients” (people who have already been seen by the physician or practice) are experiencing long delays.

But there are some things you can do:

  • If you need to see a specialist, ask your primary care doctor or nurse practitioner to send your records and request that you be seen. The office staff are more likely to respond to a colleague’s request, especially when they have all your pertinent medical information in hand.
  • Ask the office staff for the best time to call to be more likely to be able to grab a just-cancelled appointment. For many offices, that’s around 2 p.m. for some reason.
  • Ask the office staff to call you if something opens up, but don’t count on it. In busy offices, it’s easy for a staff member to forget. But some offices do keep lists and work from them.
  • Convey urgency. For example, if you have a history of skin cancer and just found something worrisome, tell the staff member in some detail what you’re seeing and how quickly it has changed or grown. If you had surgery a few weeks ago and have a new symptom or problem, describe the situation. That may get their attention.
  • Book just-in=case appointments. You can cancel if you don’t need the appointment. But be sure to call a week or two ahead of time once you know the appointment isn’t needed. You don’t want to make it harder for the next person.

 

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Hello, Healthy Toenails!

Are you toe shy?

It’s almost summer, and soon you’ll want to be walking around in sandals and flip-flops. But if you’re one of the millions of people with toenail fungus, you’ll be less likely to toss your socks.

An infected nail often will have unsightly white, yellow or orange/brown patches or streaks. It can also turn thicker, crumbly, ragged or dull, according to the Mayo Clinic. Sometimes the nail starts to separate from the nail bed.

Nail fungus, also medically known as onychomycosis, is a chronic fungal infection of the fingernails and/or toenails from ringworm, yeasts and molds, leading to gradual destruction of the nail plate. It is more likely to affect toenails, particularly the big toenail, than fingernails.

Bad News About Using a Prescription Pill 

If you’ve talked to your primary care doctor or dermatologist about your toenails, you may have been prescribed a pill, Nizoral, (ketoconazole). But the FDA has now issued an  alert.

In brief, it says, “Use of this medication carries the risk of serious liver damage, adrenal gland problems, and harmful interactions with other medicines that outweigh its benefit in treating these conditions.”

A death was reported to the FDA. A patient was taking the drug to treat toenail fungus and died of liver failure. Yes, it’s somewhat rare, but this level of warning from the FDA should not be ignored.

But There’s Still a Good — or Better — Option

There’s something else you can do that almost always works: tea tree oil. It’s inexpensive and available over the counter at most pharmacies, including Wal-Mart and Target. Just cut the affected nail or nails as short as possible (without hurting the surrounding skin), and apply tea tree oil with a Q-tip to the top, sides and end of the nail twice a day, for four to eight weeks.

I know, that’s a long time. But build it into your routine and it’s not so bad.

One thing you should know: your goal is to keep the new nail healthy as it grows in. Understand that the part of the nail that has been damaged by the toenail fungus will not repair itself or ever look right. Instead it will gradually grow out. Keep carefully cutting your nails nice and short, and be patient.

The Moral to this Story

When you have a disease or condition that is irritating but not serious, always ask for the lowest risk, least invasive way to treat it. If you doctor says something like, “There’s really only one way to effectively get rid of ______,”  ask if you might be able to try something topical, or non-prescription first.

Your goal should be to resolve your problem by using the lowest-risk, fewest side effect option.

 

 

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How Long Will You Live?

There are lots of reasons to wonder how long you’ll live. Some people need to choose a number so they can make sure they create and manage a nest egg that will last long enough. Others want to understand  whether science knows enough to ask the right questions and offer a reasonable prediction. Or, maybe you’re just curious!

The way I look at it, we’re probably more likely to practice smart health habits if we’re convinced we need to keep our bodies in good shape for as long as possible.

Underestimating our lifespan may reduce our incentive to live well.

Just so you know, as of 2010, there were more than 53,000 centenarians in the U.S. And the number of adults 90 or older in the U.S. was almost 2 million. That number is expected to quadruple in the next 40 years, by the way.

There are  good lifespan calculators available online that ask some questions and then, based on your answers, tell you how long you should plan to live (assuming you drive safely, stay away from lightening and avoid extremely high-risk adventures!).

The questions asked in these lifespan calculators are based on what is known about relative risk factors, including lifestyle, education, gender, socioeconomic level, current health problems, and others.

Four Lifespan Calculators to Try

  • livingto100.com: This calculator is linked to the New England Centenarian Study, and asks about 50 questions in all, which is more than most tools. Looking for signs of connectivity and good health practices, you’ll be asked things like “How many new friendships have you developed in the past year?”and “How do you cope with stress?”and “Do you floss your teeth daily?”  The calculator will explain the relevance of each question and  how your answer affects your predicted longevity.
  • myabaris.com (Click on “Longevity Calculator”) The tool takes into account such factors as family history, personal health and socioeconomic factors.
  • bluezones.com (click on “Tools”): Called the “Vitality Compass,” the tool asks somewhat detailed questions about such things as exercise habits and diet. The calculator will help forecast your healthy  life expectancy, which is how long you can expect to live before being diagnosed with cancer, diabetes or heart disease. The site also provides suggestions for how to live a longer life.
  • Minnesota State Retirement System: Named the “Life Expectancy Calculator,” it asks about 30 questions designed to give you a good estimate of how many more years you’re likely to have.

If you’re concerned about what the calculators are telling you, bring the results to your physician and talk about what you can do now to help ensure a longer and healthier life.

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Get a Paper Prescription…If You Can

A couple of days ago my dermatologist suggested I try a prescription form of cortisone for a small, funny spot on my leg. His staff assistant. asked me  what pharmacy I wanted the prescription sent to. Then she emailed it for me.  So far so good.

But when I got to the pharmacy, it was closed due to a neighborhood power outage. When I circled back after the outage was fixed, the pharmacy couldn’t find the emailed prescription. Not a big deal, since it was only a cream for a funny spot. But I couldn’t help think what a hassle that would have been for someone who was sick, tired, disabled, or lived far away.

I also realized that although the doctor told me what he was ordering, I wasn’t sure what percentage of medication he had ordered. Because I didn’t have his written prescription in hand, how would I be able to check to be sure I got the right drug and the proper dose?

So here’s my new policy, something I would recommend you adopt as well: Any time a physician prescribes something, ask him or her to write a paper version as well, as back up.

Not only will you be able to use the paper prescription  to check to be sure your pharmacist is giving you just what the doctor ordered, but you’ll be able to take it anywhere you want. If the first place you go to is expensive, or closed, or there’s a long line, you are free to get the drug elsewhere.

If the drug is something you’ll be using for awhile, having the paper prescription is also a handy thing to tuck in your suitcase when you travel. If you forget to pack the drug or if it runs out while you’re away from home, you’ll be able to replace it.

Unfortunately, paper prescriptions may be becoming a thing of the past. 

Just recently, a New York Times article described how a new law in New York  — designed to reduce the number of multiple narcotic prescriptions issued — makes writing a prescription by hand illegal:

“Starting on March 27, the way prescriptions are written in New York State will change. Gone will be doctors’ prescription pads and famously bad handwriting. In their place: pointing and clicking, as prescriptions are created electronically and zapped straight to pharmacies in all but the most exceptional circumstances.

 “New York is the first state to require that all prescriptions be created electronically and    to back up that mandate with penalties, including fines and imprisonment, for physicians who fail to comply. Minnesota has a law requiring electronic prescribing but does not penalize doctors who cling to pen and paper.Just as doctors putting away their pads will face a culture change in New York, so, too, will patients, who will no longer be able to shop around for the shortest waiting time or the best price for their medications.”

In the Meantime

If you live somewhere other than New York, ask for the paper version…while you still can. And even if the doc can’t give you the prescription, be sure to ask him or her to write down the name of the drug and the prescribed dose, just so you know.

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Defending Yourself Against Medical Errors

Did you know that the third most common cause of death in the U.S. is medical errors? That’s what research published in the British Medical Journal  yesterday says.

The study authors estimate at least 251,000 deaths a year from medical errors. That’s more than twice as much as the deaths from firearms, motor vehicles and suicide put together.

And the number is most likely underestimated. Many deaths from medical errors are never noted, as death certificates typically do not attribute the cause of death to a mistake, but rather to a billable diagnosis, such as “coronary artery disease” or “pneumonia.” That number  also doesn’t even include the error-related deaths in out-patient surgery centers, nursing homes, or other healthcare facilities. It also doesn’t include the deaths that happen at home, not long after leaving the hospital.

Want an example of what we’re talking about? The study authors tell the story of a young woman who recovered well after transplant surgery.  Not long afterwards, she wasn’t feeling well and was readmitted to the hospital. One test, which involved inserting a needle into the sac that covers the heart, showed no problem. She was sent home, but just a few days later was back in the hospital with an abdominal hemorrhage and died. It turned out that when the doctor put the needle into the heart sac, the needle nicked the liver, causing a sort of balloon or aneurysm, which ruptured and killed her.

Medical errors can include everything from giving you the wrong drug to removing the wrong leg. The study authors say that while human error is inevitable, we need to  better measure the problem so we can design safer systems that will reduce the  incidence and consequences of these mistakes.

Hospitals and health systems have been working on improving the medical error problem for decades. Back in 1999, the Institute of Medicine released a report that showed that medical errors were already more deadly than breast cancer, car crashes or AIDS. Now the estimate is far higher, based on studies released since that report.

The British Medical Journal study says we need to have a place on death certificates where physicians can indicate that a medical error contributed to death. They also suggest that everyone involved in health care needs to make preventing medical errors a top priority.

In the meantime, what can you do? 

  • Before you have surgery, an invasive test or a major procedure, make sure it is absolutely necessary. Ask about the alternatives. Discuss what the possible side effects or problems from the test might be and how you will be monitored to be sure those issues don’t occur afterwards.
  • Read your consent form (before a surgery or major procedure) and take the time to ask questions. Make sure the procedure or surgery is accurately stated in the consent.
  • Before you go home from the hospital, insist on a careful review of each medication you should be taking and how much, and when, and why. Often, drugs and dosages change after you’ve been in the hospital. If anything doesn’t make sense to you, insist on talking with your physician. A recent analysis by Kaiser Health News showed that medication mistakes can slip past pharmacists and home health nurses and are a major patient safety issue.
  • Keep an up-to-date list of your current medications, recent surgeries and any major procedures, and any unusual but normal-for-you lab results, and put them in a conspicuous place (like your refrigerator) in case you have to call 911. Also put this information on your smart phone, and in your purse or wallet.
  • If you visit the emergency room, urgent care center, rehabilitation center, nursing home, or another type of clinic, or even just see a new medical specialist, bring that list of medications, recent healthcare treatments and key health data with you. Offer that list to the clinicians right away; don’t wait for them to ask.

And last, but not least, assume nothing.  If something seems off,  wrong, or just unusual, or if you just have a feeling about something, ASK.

 

 

 

 

 

 

 

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The Sun: Your Friend or Your Foe?

It’s spring and summer is right around the corner. Time to think about bright sun and long days.

If you’re like me, the stay-away-from-the-sun message has begun to sink in. If you’re going outside for a walk, gardening, taking a bike ride, or even jumping in the pool for a swim, you put on sunscreen and whatever else you may need to prevent a sunburn and skin cancer.

But, it looks like you shouldn’t be quite so sun-shy. Like so many things pertaining to health, it turns out it’s complicated.

A  study published March 21 in the Journal of Internal Medicine  (subscription or purchase required) showed that people who avoid the sun and its rays don’t live as long as do those with higher amounts of sun exposure. Avoiding the sun “is a risk factor for death of a similar magnitude as smoking,” according to the study authors. 

Avoiding the sun is a new risk factor, after smoking, being overweight and being inactive, according to the researchers. This goes against the commonly held belief that if you sunbathe, you’re crazy.

The research team, led by Pelle Lindqvist, MD, of Karolinska University Hospital in Huddinge, Sweden, found that women who had more sun exposure were at lower risk for cardiovascular disease, diabetes, multiple sclerosis and pulmonary diseases than were those who avoided the sun.

What’s more, the study found that the health benefits increased with the amount of sun exposure.

But what about skin cancer? The authors reported that they did find an increased risk for skin cancer associated with higher sun exposure, “but the skin cancer that occurred in those exposing themselves to the sun had a better prognosis.”

The study looked at sun exposure as a risk factor for death in almost 30,000 women with no history of malignant cancer, followed over a 20-year period. The women in the study had been recruited in the early 1990’s when they were 25 to 64 years old. Factors such as marital status, education level, smoking, alcohol consumption and the number of children the women had had were noted. A limitation of the study was the fact that the researchers did not include other life style habits or exercise data.

Even smokers who were about 60 years of age who had the most intense sum exposure had a two-year longer life expectancy during the study period than did smokers who avoided the sun.

Why might this be? The researchers don’t know whether the positive effect of sun exposure is caused by  vitamin D, another mechanism related to ultraviolet radiation, or something else.

What should you do? Talk with your physician about your particular needs. As for me, I’m going to enjoy 10 to 20 minutes of pure sunshine most days, but use sunscreen when I’m out for longer periods.

 

 

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Should You or Shouldn’t You?

It was Shakespeare’s Hamlet who wondered “To be, or not to be”; but in health care, the question is altogether different: It’s “Should I, or shouldn’t I?”

That’s because as our diagnostics, treatments, surgeries and medications have gotten more and more sophisticated, potential benefits and risks are nuanced and vary depending on your own preferences, issues, comfort level and goals.

You can learn how to make better healthcare decision in the same way you get better at other  areas of planning and decision making in your life, including financial management, buying a car or a major appliance, or even traveling.

For some, this new reality is going to be frustrating because it would be so much easier to just be able to lean back and ask for absolute direction. Some people are still doing that, by the way, with mixed results. But the truth is, what works for your friend or your physician may not be the best choice for you. When given clear, understandable information and data on relative risk factors, people tend to weigh the options differently than do their physicians.

Who has the time or the insight to read and understand all the information that’s available to us all? None of us do, honestly —  not even most physicians, to be frank.

Here’s an example. I have a  friend (who happens to be a scientist); she was put on a statin (one of the most commonly prescribed drugs in the world, used to lower cholesterol, a factor that may lead to heart attack and stroke). After several months on the drug, she thought she wasn’t as strong as she had been, and talked to her doctor, who changed her statin to a different medication. She still felt less strong. So she did some reading, evaluated her risk factors for cardiovascular disease, and stopped taking the prescription. (I believe she informed her physician of her decision, by the way). She feels great now, and she’s exercising more  than ever before (which will undoubtedly reduce her risk for cardiac disease significantly).

Check out  “Your Medical Mind: How to Decide What is Right for You,” by Jerome Groopman and Pamela Hartzband, both on the faculty at Harvard Medical School. They discuss issues like my friend’s question about her statin and provide guidance about how you can responsibly become a smarter patient and understand the influences that sway decisions — both your healthcare provider’s and yours — about health care.

Also worth reading is Thomas Goetz’s “The Decision Tree,” which describes how people who engage in their healthcare decision making achieve better outcomes. He talks about why some screening tests are a better bet than are others and explains the difference between smart screening (early detection that saves lives) and dumb screening (overuses technology and often causes anxiety and unnecessary interventions).

These books may help you feel more capable of asking the right questions about the relative risks and benefits of everything from an annual mammogram or PSA test to the merits of back surgery versus medication and physical therapy.

The next time you visit a healthcare provider, practice these skills and test your ability to ask the right questions and evaluate your own preferences. It’s worth it; the chances are you’ll get better outcomes.

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Going Home from the Hospital? First Talk About Your Drugs

When you’re in the hospital and you hear you’ve been OK’d for discharge home, the last thing you’d  want to do is to start asking questions. The natural urge to is grab your suitcase and head for the closest exit.

But last week Melissa Walton-Shirley, M.D., a cardiologist in Glasgow, Ky., raised an issue that is applicable to anyone who is ready to leave the hospital.

Her article, “My Top Six Easily Preventable Causes of Patient Death and Morbidity,” published on medscape.com March 15, 2016 (password needed), was focused on preventing serious medical errors and overlooking key information about patients. But one key paragraph caught my attention. It’s about drugs.

No matter who you are and why  you’ve been admitted to a hospital, it’s critical that, before going home, you  talk about drugs with your doctor. You should carefully review both the drugs you were taking, if any, when you landed in the hospital and any changes that were made in those drugs and dosages during your hospital stay.

It doesn’t matter if you had a baby, were in for knee replacement surgery or had a near-fatal heart attack, or anything in between.

That’s because sometimes the medications you were taking turned out to be part of your problem. Or, your surgery or the diagnostic exams you had highlighted a brand new problem you hadn’t known about. Or perhaps you’re coming home with a completely new diagnosis.

Other times, the drugs you were taking may have had a role in causing your problems. For example, you may have been taking too high a dose of medication designed to lower high blood pressure, and thus you fainted due to low  blood pressure. Or perhaps your thyroid medication was too high, which caused palpitations , and you ended up in the emergency room.  Maybe your blood thinner caused gastrointestinal bleeding.

Typically, doctors almost automatically click “continue home meds” when they discharge a patient from the hospital.

Instead, they should click “reconcile medications at discharge.” That means the physician, often in consultation with the patient and family, compares what the patient was taking at home and decides, drug by drug, what should change, given what was learned during the hospitalization.

Ask for that. 

 

 

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Uninformed Consent

The last time you consented to a procedure, test, or drug, were you told the whole story? Research suggests that you most likely were not.

There are a lot of reasons why this happens, but there are some things you can do to be sure that when you give your consent to having something done, your “yes” really means “yes,” and  you genuinely understand.

A True Story

When I was a nursing student at a large university hospital in Los Angeles, I was taking care of a man who was slated for surgery the next day. He had a large tumor in his neck. I was asked to review his consent form with him and ask him to sign it.

Looking over the form, I noticed that the surgery would include removal of his tongue, and because that would have a significant impact on his life, I specifically asked him if he was aware that he would be speechless for some time, perhaps permanently. His answer wasn’t what I was expecting. “What?” he asked.

“Well, as part of the surgery, and I am sure your surgeon explained this to you, your tongue will be removed. As a result, at least initially, you will not be able to speak,” I replied.

He was shocked. I was shocked that he was shocked. He said he had never been told. He picked up the phone and called his wife.  She, too, was completely surprised. He asked me what he should do. I told him he should talk to his surgeon before signing the consent form.

A few weeks later I learned that he had ended up checking  himself out of the hospital that night and having a slightly different surgery at another hospital a week or so later. By the way, he didn’t end up having to have tongue removed.

The moral of the story: know that you can’t assume you’ve been told all that you need to know to make a decision that is right for you.

Uninformed Consent Is Common

Just three out of 100. That’s how many patients were told everything they needed to know before agreeing to an elective (optional) invasive procedure, according to a study published in JAMA Internal Medicine last year. It’s very sad.

The study looked at how many people had heard all the information they needed before consenting to have a heart stent placed. The research found that too many people are not told the whole story, the full range of pros and cons related to a procedure, test or drug.

John Mandrola, M.D., a cardiac electrophysiologist at Baptist Health in Louisville, Kentucky, put it succinctly in an article in Medscape this month:

“Providing a truthful and complete informed consent lies at the core of being an ethical and moral caregiver. If a patient is harmed during a procedure — one in which benefits were greater than harms, and that patient understood the risk — then we sleep at night.” But he added that when the procedure is not necessary, but the patient is led to believe they “need” the procedure, then there is a big problem.

What You Should Do

Dr. Mandrola says there are things you know in order to consent to a drug, test or procedure. Before consenting, be sure you:

  • Understand that you have a role in making the decision.
  • Understand the issue and the decision you are making.
  • Know the alternatives.
  • Know the pros and cons of the alternatives.
  • Know the uncertainties.
  • Express and discuss your preference.

The bottom line: With most of health care today, there’s room to consider a patient’s preference. There are almost always a range of options. There is rarely just one “correct” approach. Your knowledge, understanding and personal choice matter.

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