Risk

1. Risk Or, Hippocrates was wrong P. Mukherji

2. Primum non nocerum -HIPPOCRATES

3. First do no harm • FIRST: implies that this is a cardinal and overarching tenet of medicine • The statement also implies that this is possible.

5. Better motto: Please try and kill as few patients as possible, while hopefully healing and helping as many as possible.

6. Please stop me • Please interrupt • Please look it up

8. 91 yo WM s/p trip and fall • +head injury: abrasion • NT head/spine, full ROM • No concerning sx, no ASA/Coumadin • CT?

9. RULES to help us? Canadian Head CT NEXUS II New Orleans Criteria

10. To scan or not to scan? • Spin em all and let God sort em out • Nope, he might get a brain tumor

11. CT shows small SAH • SDH is more common in trauma • Epidural is more common in trauma • He has an aneurysm • He needs ICU time • He needs a monitor

12. Pt. admitted for observation • Falls off the bed(!) • When transferred back to stretcher stops breathing • Regains VS, is transported to CT • Stops breathing again!

13. CT shows? • C-spine is crumply at C2 • CT head is clean • Attending read later finds initial CT finding to be motion artifact

14. Did we do wrong? • Pt. was admitted for his own safety • Harm came to patient • Admission led to harm • Should we change practice? • CO- vs. O-MISSION

15. Would you do it differently next time? • Head CT please • How about just good instructions

16. Doctors are biased* • Routinely overestimate benefits of intervention • Routinely minimize risks of intervention *Surgeons!

17. House of God? • FAT MAN’s RULE #13 • “The delivery of good medical care is to do as much nothing as possible”

18. But it’s not just about doctors • We all routinely underestimate everday risks • High frequency, unlikely events • We tend to demonize and overestimate rare events • Low frequency, very unlikely events

19. Did you ever fall? • Over your lifetime, falling is a significant risk • Falls in the elderly are a problem, should you be attentive to it already?

20. What’s most likely to kill ya? • Shark attack • MRSA • Flu • Fall

21. Actual lifetime odds of dying • Sharks: 1 in 60,453 • Falls: 1 in 218 • MRSA: 1 in 197 • Flu: 1 in 63!

22. Risk vs. Benefit • We accept the risk of anaphylaxis when prescribing antibiotics, • AS LONG AS • We think there is some benefit to the antibiotics for the pt.

23. Overutilization? • Overuse is defined by multiple federal overseers and review boards as: • Testing for which no (or minimal) benefit to the patient exists

24. Who has prescribed Abx? • …for sinus pressure? • …for cough/bronchitis? • …for sore throat?

25. 31M with fever and sore throat, has exudates, tender ant. nodes, and no cough • Bicillin shot! • Z-pack • Rapid strep, Cx if neg • Rapid strep, do what is says • Suck it up, wuss

26. It’s cool, you haven’t killed • (Probably) • But you haven’t helped • …and you might have killed

27. Sore throats • 14 million visits in U.S./yr. • Steroids/NSAIDS >> Abx • NO evidence that it helps abscess • ONLY evidence on rheumatic heart from worst military outbreak ever • NNT? 40,000 • NNH? 5 minor rxn, 6 to recur, 2500 major Smartem.org, David Newman, AEM 2010

28. Let’s talk about • Our cognitive errors • Assessing and communicating risk • Balancing risk and intervention

30. Unintended Consequences** • Interventions ALWAYS have the potential to create unanticipated and unforeseen events • Perverse

33. Every intervention/test carries RISK and UNCERTAINTY • RULE #1 • LAW of UNINTENDED CONSEQUENCES • We are expected to detail these risks to our patients • Informed consent: risk/benefit- uncertaintyon both ends

34. Risk assessment • We suck at this • Probability of Occurrence x Impact of Risk Event

36. We suck at probability, too. • Statistics, anyone? • You test a bunch of people for HIV • 1 is positive • Likelihood of true positive?

37. Math! • Test is 99.99% sensitive AND specific • Out of 10,001 men, 1 has HIV • So what do you do with your positive guy?

38. Sir, your rapid test was positive, you need a repeat test but… • It’s very likely correct • It’s very unlikely to be correct • Probable, but could be wrong • Probably wrong

39. Great for negatives (screen) • One pt. with HIV will be positive. • One other pt. will have a positive test. • 50% chance that this is a true positive** • PPV = 50% (RULE #2)

40. Testing? • On low prevalence groups leads to higher rates of false positives** • RULE #2

41. Screening • Hgb A1C • Mammography • PSA

42. PSA • Screening PSA will result in an absolute mortality reduction of 33%

43. PSA • 17 of 100 men will get a dx of CA • 3 will die if untreated • Treatment will save the life of 1 of 3* • Treatment will kill 1 of the 17 • 10 of the 17 will be incontinent and/or impotent

44. How you present the data matters • “98.5% safety from a particular disease” • That is exactly 1 in 63, the odds that you’ll be killed by flu in your lifetime.

45. How likely are you to pass the inservice? • 50% • 90% • 95% • 98% • 99%

46. You did not grow a brain that likes small or huge numbers • All your brain sees is either a really high (98%, 99%) likelihood and rounds up • or a really low (1%, 2%) and rounds down

47. Probabilities are percentages • But real numbers work MUCH better • RULE #3: USE REAL NUMBERS • Want someone to go home? • “98% you’re ok!” • Want someone admitted? • “1 out of 50 you’re dead!”

48. How do some docs manage risk? • TESTS • We’re even told that pts. WANT tests. • Testing does not reduce legal action • and might increase it

49. Every test is an additional intervention** RULE #1 • Failure to follow up • Failure to interpret correctly • Failure to pursue to the correct test • Alteration of the presenting frame • Incidentaloma • Radiation

50. Prevalence of incidental findings in trauma patients detected by computed tomography imaging • >3000 pts. • 990 (32%) had Type I findings • 1274 (41%) had Type II findings • 631 incidentalomas concerning for nodules, masses