Just being alive has its risks

Let me start with a quote from a journal article in Gastroenterology: “10-year risk for a gallstone event was 3% in men with one small stone, and 23% in women with multiple stones. Although the long-term incidence of symptomatic gallstone-related disease is [8% and] not trivial in these patients, it is low enough to support the current standard of care — in general, no intervention unless symptoms develop.”

As I read the above quote, I was struck by how perfectly it depicts the difference between evidence-based medicine and the art of medicine. In the quote above, there are solid numbers relating to the outcome of incidentally identify gallstones. These gallstones are identified when the patient has an ultrasound for other reasons than suspected gallstones or nonspecific reasons. The question as to how to manage such gallstones goes back many years. 30 years ago, during my medical school training, the standard answer for incidental gallstones was to simply remove the gallbladder. The argument was that firstly, the gallbladder was not necessary for normal functioning of the body, and secondly, gallstones could cause serious complications if ignored.

The article that I quoted above brings hard numbers to the question of whether a gallbladder should be removed or not, when stones are incidentally found. Clearly, there is a wide range of risk related to leaving such stones behind. In women with multiple stones, the risk of complications is 23%, which is very significant. The risk for men with one small stone is 3%. Now comes the question: is this considered a low risk or not?

I am the first person to say that the smartest computers available today cannot answer whether humans consider 3% to be low risk or not. Admittedly, telling someone that they have far less than a 3% chance of winning the lotto doesn’t stop them from buying tickets every week. Telling people that they have far more than a 3% chance of developing life-ending diseases secondary to smoking, unfortunately has little effect. In the future, computers will be able to say whether individuals, given all of their personal specific parameters, would consider 3% high or low. But the patient still has to make the choice.

For example, someone who is in good health, takes no medications and plans a trip around the world, might consider 3% too high. Given the incredible advancements with laparoscopic surgery, a typical patient undergoing the removal of their gallbladder, is eating within 24 hours and goes home not much later. In comparison to the nearly barbaric surgery that was performed decades ago, whereby a very long incision was made on the upper abdomen, laparoscopic surgery is truly miraculous.

In the past, patients would do fine after the specific removal of their gallbladder. But many patients suffered significantly from the incision. The effects of the incision were so significant that patients who suffered from weak hearts and poor lung function, could sometimes simply not tolerate the surgery purely because of the incision. That is why laparoscopic surgery has been so revolutionary. And that is why, some people might very well consider 3% too high a risk, given the low risks of present-day surgery.

The question that arises from all of this, is how do people measure risk and more so, make life critical decisions based on their impression of that risk. It’s well known that there are people who are specifically called “risk takers”. People who decide to climb Mount Everest are risk takers. People who cross against a red light are also risk takers, but to a lesser degree.

There are some people who live by the principle that life has no meaning without taking risks. In today’s world, we are surrounded by risk takers in the technology realm. Every person who creates a startup is taking on a tremendous amount of risk. There are stories of people mortgaging their homes to advance their startups. The sad thing is that, in percentage terms, very few startups succeed. The ones that do, sometimes change the world.

I think it’s fair to say that Google and Facebook have very much changed our daily lives. Although other major companies started off decades ago, at that time they were also startups. Microsoft and Apple also fundamentally have changed the world. All of these startups experienced major downs that sometimes approached total failure. But their leaders pushed on, and succeeded. If not for these risk takers, we would still be living in a world without smart phones, home computing, advanced graphics, many advances in medicine, and a far less impressive set of options at the movie theater.

When a doctor presents the risk associated with a medical disease, patients don’t often realize that the doctor’s own biases very much affect the way in which the information is presented. Going back to our gallstone example, a doctor could easily say the following: “by the way, we found a couple of gallstones in your gallbladder but it’s nothing to worry about”. Another doctor would say: “you should know that we found gallstones in your gallbladder and you do need to consider having a preventative removal of your gallbladder”. In both of these cases, the doctor doesn’t quote  the actual percentage risk. The doctor applies his or her own impression of what significant risk is to the message passed on to the patient. And the reality, even today, is that patients, even those with PhD’s after their name, rarely challenge the doctors in their statements. Very few patients will ask the doctor “well, what is the actual numerical risk if I do or don’t have my gallbladder removed?”.

The Internet is still a very dangerous place to visit when you don’t already have a strong foundation in the specific topic you are looking up. If I wanted to double check my car mechanic’s assessment of my car, I really don’t think I would succeed in getting any usable information from the Internet, simply for the fact that I don’t know what questions to ask. The same is true in medicine. If a patient was to surf the Internet looking for more information on gallstones, the patient might very well come across the specific article I quoted above. So the patient would now have the actual numbers, but still be faced with the same questions: what actual number constitutes too much risk?

Maybe this speaks to the role of physicians, even in 50 years from now. Maybe it will be the primary role of physicians to help patients come to terms with what they consider to be too much or little enough risk. It may be, that in 50 years from now, we will have computers that can simulate human emotions and personality well enough such that these computers will also be able to help patients manage their risk assessments. If so, maybe this will be the end of what humans can uniquely bring to the table. At least in the short term, even when we have good solid research and hard numbers about a particular disease, it is critical that doctors take the time to help patients come to terms with their situation. This is truly the art of medicine. And it is still just as important as it was centuries ago.

Thanks for listening.

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.