Risk perception in healthcare

Risk vs. Reward

Risk vs. Reward

Healthcare decisions made by an individual often follow flawed logic based on the personalized perspective of the patient.  A great example of this type of irrational behavior can be seen at any “craps” table in Las Vegas.  Craps is a dice game where the player continues to roll a pair of dice to hit a specified number before rolling a seven.  Dice have six sides numbered one through six.  Out of thirty-six possible dice combinations, the probability of rolling the number seven is 16.7% (1 in 6) and is the most likely outcome in this situation.  While anyone with a calculator can figure this out, once the dice are placed in a player’s hand the statistical probabilities are usually ignored.  The player knows that seven is the most likely number to be rolled, but the player is confident that he/she will have better luck.

When presented with therapy options and risk/benefit ratios, most people display the same self-confidence as a high rolling gambler.  They may acknowledge that risks exists with a particular prescribed therapy, but are sure that those risks only apply to “other people” taking the medication.  This can be even more alarming in terms of public health as an overconfident assessment of risk may increase outbreaks by infectious disease carriers.  One study in Philadelphia of 5871 individuals tested for HIV found that 2/3 of the individuals that tested positive had assessed their own risk as zero or low.  In the study, all cases were new diagnoses and 90% of the HIV positive patients never, or only sometimes, used condoms.[1]

The emphasis on patient-centered care has evolved into a push for Shared Decision Making (SDM) in medical practice.[2]  Misjudged self-perception of risk brings the reliance on patient decision-making into question.  Within a consumer-driven healthcare system, patients are empowered to demand treatments if they “believe” it will help their ailment.  This puts the physician in a customer service role and that of a consultant similar to a financial advisor providing an investor with stock advice.  Patient “buy-in” on the treatment plan may improve compliance and add placebo effect-like improvement, but may lead to an increase in unnecessary therapies.

The psychological phenomenon surrounding perceived risk has infiltrated health decisions by patients, but what about the investigators researching new drug therapies?  Is it possible that well-meaning scientists and clinicians that see potential adverse events during early stages of drug development are blinded by this same overconfidence?  The attachment (via employment or other contractual arrangements) to the drug being studied puts the researcher in a position where personal emotions could be similar to the dice player.  The potential for this unintended bias helps build the case for a requirement of independently funded research in addition to the pharmaceutical company researched submitted for drug approval.

Variations between actual compared to perceived risk can influence decision making, so the challenge becomes accounting for those variations or implementing strategies to eliminate them.  For example, a gambler may go to the casino with a friend not for just social reasons, but so the friend may provide a “voice of reason” when the gambler is being irrational.  We can use a similar strategy in healthcare by adding an independent tertiary observer to the patient-physician SDM framework or the pharmaceutical company-FDA transaction.

[1] Nunn A, Zaller N, Cornwall A, et al. AIDS Patient Care and STDs. April 2011, 25(4): 229-235.

[2] Stiggelbout AM, Van der Weijden T, DeWit PT, et al. Shared decision making: really putting patients at the centre of healthcare. BMJ 2012;344:e256.

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Joey Mattingly, PharmD, MBA is an assistant professor at the University of Maryland School of Pharmacy located in Baltimore, Maryland. Joey has managed retail and long-term care pharmacy operations in Kentucky, Illinois and Indiana. Leading Over The Counter is a blog of Joey's views and opinions on the topics of pharmacy leadership and management and do not represent the University of Maryland, Baltimore. Joey can be followed on Twitter @joeymattingly.

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