What Do You Do When You Are Sick?
Case #1 - Episode 2 - Understanding Evidence and Knowledge
THE PATIENT JOURNEY:
The young woman in Case #1 had urinary symptoms of dysuria (burning when urinating), frequency (frequent urination), nocturia (getting up at night to urinate) and mild abdominal discomfort. Her first thought was to wait and see if the urinary discomfort would get better.
Should she do nothing and hope her condition will resolve on its own?
Benefits of Doing Nothing:
Sometimes, minor illnesses or injuries can resolve on their own without medical intervention. This approach saves time, money, and avoids potential side effects of medications. Symptoms are warnings your body gives you that something may be wrong. Actually, over 70% of symptoms will resolve on their own without any treatment if you are in good health because your body can repair itself beautifully. Another 25% of conditions will resolve, albeit a lot longer and half of those with much more discomfort without professional medical treatment.
Anecdote:
Last fall I had a cold that developed into a sinus infection a couple of weeks later. I waited another 2 weeks before consulting my doctor (I don’t treat myself) to prescribe an antibiotic. The infection resolved in 48 hours. I might have suffered another month or two doing nothing. Had I contacted her in the first 10-14 days I would not have suffered an extra 2 weeks.
Risks of Doing Nothing:
Ignoring symptoms can lead to worsening of the condition or complications. Consider the 25% of conditions can be ameliorated with medical treatments and the course shortened substantially treated by a licensed healthcare professional. X-ray studies of large apes in Africa reveal broken bones that are healed, but the pain and deformity would be intolerable for most people. If you have any chronic disorders or a condition that is recurring, then symptoms can have far different significance.
Under 5% of symptoms represent conditions that definitely need expert medical advice without which increased morbidity will occur (really bad things will happen). The real challenge for the non-physician is knowing which symptoms belong in which category. There are some serious illnesses or injuries if untreated will lead to long-term health consequences or sometimes death.
In my career I have admitted patients to the hospital who appeared well, but were dead in less than 12 hours. I have seen others who with lethal illnesses like spinal meningitis that I treated quickly and recovered completely. Luckily, no one ever left my office and died soon afterward.
Deciding if someone is seriously ill can sometimes be challenging even for skilled clinicians. Sometimes it’s just a feeling that something is not right based on the experience of seeing lots of sick people.
Anecdote:
A young woman called my office one morning and wanted to be seen that day for abdominal pain that she had had all night. This is a complaint that should not be ignored because of the number of conditions it can be (differential diagnosis). I examined her in the late morning after her pain had resolved and found her to have a completely normal abdominal examination. Something about her onset of pain, the duration of 6 hours, and the description bothered me. I asked what she had done for the pain. She indicated she took a pain pill. I asked more about the pain pill, but she did not know the name of it. I discovered her dentist had given it to her for a root canal, which meant it was likely a narcotic (from Latin “to make numb”). Narcotics can numb the body’s physical signs of serious illness. I asked her to remain in the office for a few hours giving her only sips of ice cubes (in case she needed surgery). Within 3 hours she exhibited classic signs of appendicitis and had an emergency appendectomy later that day. Allowing her appendix to rupture would have meant she likely would have never had children because of damage to her fallopian tubes that would have been exposed to the massive inflammation, infection and scarring.
THE PATIENT JOURNEY:
The 24-year-old patient’s urinary symptoms persisted until the next day so she decided to call her physician. She could not get an appointment for a week, so she went to the pharmacy to see if there was something she could take to allow her to wait until the appointment. The pharmacist gave her an over-the-counter (OTC) medication and cautioned her about the possibility it might not resolve her problem.
Could she treat herself based on friends and family advice or the internet?
Benefits of Treating Yourself:
Quick access to potential remedies or treatments without the need for a doctor's visit. It might provide relief for minor ailments.
Risks of Treating Yourself:
Unlike watching a YouTube video to repair your sink, deciding to treat your body is a different level of risk than getting your kitchen floor wet. Someone without a medical license as well as years of experience may give you advice that is not accurate or unsuitable for your specific condition.
THE PATIENT JOURNEY:
The OTC medicine from the pharmacist helped a little, but her symptoms persisted. Then our 24-year-old patient with urinary symptoms looked on Google for self-treatments of her symptoms. Below is what she found. How could she know what she had and whether any of these treatments were right for her?
Is Artificial Intelligence on the Internet Good for Medical Diagnosis and Treatment?
Getting the diagnosis right is critical. When the diagnosis is wrong, then the treatment will be wrong. Starting out wrong delays proper medical care and possibly worsening of symptoms. It is far more important to know how to evaluate information for a medical diagnosis than it is for a DIY YouTube video on how to repair your stopped up sink.
There is a wealth of information available online, much of it accurate, that can help you when you are sick. However, distinguishing between accurate information and misinformation, particularly from those trying to profit from alternative treatments and supplements, can be challenging without healthcare expertise.
What is Knowledge and Evidence?
Properly analyzing any information also requires knowledge. The scientific method has been accepted by scholars since it’s invention in the 17th century to discover knowledge for decision making. It ranks evidence in the following categories:
• Level A (randomized controlled trial/meta-analysis):
Randomized control trials (RCTs) are the gold standard for evaluating therapeutic interventions. They involve randomly assigning participants to either treatment or control groups, reducing bias and confounding factors. For example, researchers might recruit 1000 healthy people with a specific illness: 500 receive a real treatment, and 500 receive a placebo. Only the researchers know who gets which pill. After a set period, they analyze the results using statistics to account for natural symptom resolution. This rigorous process is essential for FDA drug approval and is costly due to the need for extensive testing and detailed medical examinations.
Other researchers repeat the trial to test the results are accurate. A metanalysis is lots of randomized controlled trials (RCTs) summarized.
• Level B (other evidence):
Sometimes researchers can’t find 1000 people with an illness to do a RCT or they don’t know the people have the illness until after they have other treatments. If the patient had a serious illness, e.g. cancer, an RCT would be unethical by not treating patients with anything. Other studies involve multiple researchers treating people with an illness with a certain treatment.
• Level C (consensus/expert opinion):
The lowest level of evidence comes from expert opinions, clinical experience, descriptive studies, or expert committee reports. Despite being lower quality, this evidence is valuable for understanding rare conditions, or when higher-quality evidence is unavailable.
Recently, Google’s method of determining search results was revealed to show minimal to no use of the quality measure, E-E-A-T (experience, expertise, authoritativeness and trustworthiness), in displaying websites.1 Similarly, artificial intelligence on the internet looks at all information, but cannot distinguish between scientifically proven claims and unproven assertions. Would you ask someone how to get well who had no healthcare experience, no medical training, no legal authority to render a therapeutic opinion, and was untrustworthy?
Testimonial evidence of a friend describing improvement in a symptom after taking a supplement is not evidence that meets the definition of the scientific method. Would the friend have gotten better anyway? Indeed, we know that 85% of symptoms will resolve without doing anything. How can you possibly know if something really works when it will always work 6 out of 7 times (because the problem will resolve itself on its own)?
Opinion:
After four years of pre-med science in college, four years of medical school, and three years of residency that were dedicated to gaining this expertise, and decades of doing it, I still find medical diagnosis challenging. Before you do anything to your body based on something you read on Facebook, Instagram, or Tik-Tok, you should verify that the original source of your information is listed on some U.S. jurisdiction’s medical licensing board website. Otherwise, caveat emptor.
THE PATIENT JOURNEY:
Except the product recommended by her pharmacist, none of the other products our patient found listed on the internet were tested using methods above. Our 24-year-old female with urinary symptoms decided against self-treatment and called her doctor back, obtaining an earlier appointment due to a cancellation.
PATIENT ACTION:
When you are sick:
Call your doctor
Ask your pharmacist
Know what symptoms can be safely treated without professional advice2
Remember the scientific method when deciding about healthcare
Preview:
The next Episode will discuss how scheduling and access for patients impacts care.
I plan to republish here my patient booklet: Dr. Wenner’s Home Remedies and Medical Practice Guide