It would seem that the more patients understand about their health issues, the more likely they would be to make good choices in collaboration with their physicians. However, in the age of the Internet, information can quickly become overwhelming, and conflicting findings from the multitude of studies reported in the media can leave even the most educated consumer confused.
Take, for example, recent reports that offer up new views on the health impact of alcohol and coffee consumption. A study published in the October 2013 Mayo Clinic Proceedings found that too much coffee appeared linked to increased all-cause mortality, while two studies published Aug. 15, 2017, by Annals of Internal Medicine discuss a potential link between coffee and reduced mortality. A study in the Aug. 8, 2017, Journal of the American College of Cardiology discussed possible health benefits of consuming alcohol, and another in the September 2017 JAMA Psychiatry offered caution about the high prevalence of problem drinking in the U.S.
Patients today often come to appointments with questions about the latest health news story, said Joshua Miller, DO, an internist at Cleveland Clinic in Ohio, where he also is vice president of regional hospitals and family health centers. He said he sees this most commonly in patients who are trying to change their lifestyle, usually because they have been told they need to watch their weight, their blood pressure, or their cholesterol.
“Then they start searching for information about the best things they can do for themselves,” he said. “I really appreciate patients who are trying to educate themselves.”
Richard L. Kravitz, MD, FACP, an academic general internist who supervises residents in outpatient and inpatient settings at the University of California, Davis, said he finds that patients are more likely to bring up studies that show something has a harmful effect than ones that purport to show health benefits.
“Patients are really concerned about the latest article that claims that dietary soft drinks cause cancer or heart disease; they are less likely to talk with their physicians about articles that promote the putative benefits of coffee or alcohol because people are either using those substances or they are not,” he said.
Dr. Miller said he believes that the most important thing to do in these situations is to listen and determine what the patient really wants to know.
“What are their expectations from bringing up this study? Are they really interested in making major changes in their lifestyle, or are they just looking for a bit of guidance or reassurance?” he said. “Understanding where they are coming from when they come in with these studies initially helps guide the discussion.”
It can also save a lot of time, he said, because it allows physicians to get directly to the specific question rather than explaining all the varied nuances of a particular study, the details of which may not be very important to the patient. Dr. Miller noted that he learns a lot from these types of conversations, as they can lead to better shared decision-making with his patients.
“I always want to know why would the patient want to change their lifestyle by reading one thing that they saw on the Internet, or from a study that they saw in a magazine,” he said.
As part of his exploration, he will ask patients who come in with studies if they have ever made any health changes, such as adding nutritional supplements, based on information they read or advice a friend provided.
“It helps me understand the patient more regarding how they are living their life and how it's not just a physician that they may listen to,” Dr. Miller said. “We have to understand that there is a lot of information out there, from advertisements, from studies, and the opinions of friends and family, and be willing to work with the individual, depending on that information that they are given.”
But what about when patients inquire about studies that draw seemingly conflicting conclusions? Dr. Kravitz encourages physicians to be honest about the fact that uncertainty is not uncommon with emerging research.
“Until questions are answered with definitive studies, such as large, randomized controlled trials, we just have to use all the information that we have and consider both the potential benefits and the potential harms of the substance or treatment that we are talking about,” he said.
Eliseo Guallar, MD, DrPH, who is involved in population research studies at Johns Hopkins University in Baltimore, agreed that patients and clinicians should be very cautious about making any definitive medical decisions on the basis of a single study.
“There are very, very, very few studies that are so landmark or big or unique that they should modify practice,” he said, adding that a change in practice patterns should usually be based on more definitive research and evidence-based guidelines.
When guidelines aren't available, he said, the best approach is to remain focused on “the basics,” such as making sure your patients' blood pressure, glucose, cholesterol, and weight are well managed.
“These are the areas which we know are clearly modifiable risk factors and for which we have effective interventions, so first make sure those are in check. Then let's try to build on that,” he said.
If something is likely to be harmless and has some possible benefits, such as drinking coffee, Dr. Kravitz said he will tell patients to keep doing what they are doing. “But if the potential harms haven't really been worked out very well or there are signals in the literature that there might be problems while the benefits remain highly uncertain, then I try to wave people away from that. I think that's all we can do,” he said.
He said one major area of uncertainty is nutrition, as dietary recommendations have changed radically over the years. Where reduced-fat diets were once encouraged, especially for patients at risk for heart disease, carbohydrates are now seen as a bigger culprit, with certain kinds of fats actually being seen as beneficial.
“The story is not completely in,” he said.
According to Dr. Miller, the key to navigating conflicting health findings is to remind each patient that he or she isn't a statistic, but rather a person with his or her own unique set of facts. For example, in the face of conflicting information about coffee consumption, a key issue for him would be if the patient has a condition that could be worsened by coffee, such as reflux.
“Understanding their own personal health risks” is essential, he said.
Dr. Kravitz pointed to the example of a patient who has been advised to make a change, such as to stop drinking alcohol, but then brings in a study showing some benefit from alcohol to justify continuing to imbibe. Talking to that patient about individual health risks, and reiterating the reasons for the original advice, is crucial, he said.
“For a patient with a history of alcohol use disorder or who has been involved in drunk driving episodes or who has significant liver disease, it is important to tell them that the kind of people that were studied in this study were not like them, in that they hadn't had previous problems with alcohol,” he said. “You have to share that not every study is applicable to every individual.”