Avril Danczak: When does risk factor management lead to harm?

avril_danczak“The operation was a success but the patient died.” This old jibe, usually aimed at surgeons taking a narrow technical view of the outcome, seems out of date now. There is rather less arrogance around in medicine—no one can feel they know it all in today’s complex world.

However, perhaps the spirit of the accusation could be laid at the door of physicians these days. Guidelines and protocols can help to ensure that the care given is evidence based, meticulously applied and systems put in place ensure that all eligible patients receive what they need.

But are all patients eligible? And should thoroughness be the only consideration when we plan a patient’s risk factor management? Take a 75 year old man with a history of hypertension (poorly controlled), who ended up having with a stroke. Thankfully, he made a decent recovery with only a little leg weakness and a scary stay in hospital to show for it. Obviously he doesn’t want another stroke and obviously there are risk factors to be managed. Where did this approach lead?

Well his blood pressure came under control for sure; scared by the stroke he actually started taking his tablets. He also took his dual anti platelet medication (Aspirin and Ticagrelor) religiously, stuck with his statin and gave up smoking. “Fantastic, what a result,” we might think.

Hang on a minute though; what about that admission to hospital with maleana and hypotension. The gastroscopy did show gastritis, so he was started on omeprazole. His haemoglobin continued to decline and he needed blood transfusions, and recurrent admissions. Puzzled, by the fact his colonoscopy was normal (where was that iron deficiency coming from?) a bright spark in the hospital even arranged a haematology opinion. The cardiologist got involved when his anaemia tipped him into cardiac failure. In the Out Patient letters the stroke physician mulled over the idea that in a few months time they might discuss his treatment with the cardiologists, who are also pretty keen on preventative treatments.

A  GP could not stand the uncertainty any longer, stopped his aspirin and ticagrelor, then  after a decent interval put him on clopidogrel because after all no one at risk of a stroke could possibly be left without anti-platelet medication. His anaemia resolved and he stopped being admitted with malaena.

His risk factors had been impeccably managed…yet he came perilously close to death as a result. Bleeding, anaemia, and heart failure are the kinds of serious matters most of us would want to avoid, yet “preventing a stroke” somehow took precedence. If managing risks to prevent something that has not happened yet causes harm (which was manifestly the case for this man) then he is on the wrong end of the deal. Risk factor management has potential harms as well as benefits…and if the harms come before the benefits then the risk factors must be accepted or managed in some other way.

Younger doctors I work with, who have grown up with guidelines, get very anxious about risk factor management. I have been asked “Is it OK to stop statins in a 95 year old with Alzheimer’s confined to bed in a nursing home, blind, incontinent, with a dense hemiparesis?”

It might be useful to bear in mind this useful definition of need: “need equals the capacity to benefit from something.” Drugs for risk management are about prevention. If the thing to be prevented has already happened, the preventative drugs have become redundant. If those drugs create other disease and harm (for example, GI bleeding heart failure anaemia) then those drugs should be stopped. When the patient has recovered, then it is time to have a proper shared decision making conversation about risks and harms of the treatment. Even better, have those discussions before starting on the treatments. Let us not have anyone dying from impeccable risk factor management.

Avril Danczak is a GP in Manchester and a Primary Care Medical Educator training General Practitioners on the Central and South Manchester Specialty Training Programme for General Practice. She is currently working on a patient safety project about diagnosis in General Practice.

Competing interests: I have co authored a book called Mapping Uncertainty in Medicine: what do you do when you don’t know what to do? by Avril Danczak Alison Lea and Geraldine Murphy. RCGP books.