GPs’ understanding of the benefits and harms of treatments for long-term conditions: an online survey

Patients currently cannot weigh the true benefits and harms of tests and treatments and usually consent with only a poor understanding of their risks. Doctors can no longer claim ignorance about this ignorance. They have a duty to inform their patients better.
The Bolam principle (that if a doctor reaches the standard of a responsible body of medical opinion, they are not negligent) was overturned in 2015 by the of the Supreme Court’s landmark decision in Montgomery v Lanarkshire Health Board. This confirmed that a patient’s right to self-determination in treatment decisions triumphs over medical paternalism. Patients must now be properly advised about their treatment options and the risks associated with each option so that they can make informed decisions when giving or withholding consent to treatment. In other words, the principles of informed shared decision making must be the norm.

The reason treatments that are not that good continue to be recommended include: true uncertainty, denominator neglect, framing, incentives schemes, peer group pressures, and lack of easy access to the relevant Numbers Needed to Treat (NNT) and Numbers Needed to Harm (NNH).

When there is true uncertainty then the risk cannot be quantified. In denominator neglect, stories about the numerator (those that have things happen to them) rather than the rest of the denominator (those who do nothing and to whom nothing happens) are remembered most. In framing, the same risk information can either be portrayed as dangerous or safe and influences choices.

Patients cannot make informed shared decisions and consent to treatment if they (and their doctors) do not know the relevant NNT and NNH. Clinicians’ poor understanding of the benefits and harms of medical interventions and the tendency to overestimate the benefits of treatments is a system failure but clinicians have a responsibility to press for NNT and NNH information to be easily accessible. The absence of this essential should no longer be tolerated.

Risk scores for tests and treatments need to be available to inform everyday decision making. There are NNT/NNH websites like http://www.thennt.com but they are neither comprehensive in content nor widely used. Patients and doctors also need to benchmark their own understanding and tolerance of risk and make this clear when they share discussions about recommendations.
If patients are helped to better understand their risk, they should make more informed and personal choices about their care (and they may often decline care). Fully informed shared decision making should be our usual standard.