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Nothing is free in medicine.

Photo by Artem Beliaikin on

I say this often in clinic. If you’re a patient of mine, you may have heard me say it. There’s a cost to every decision we make (or don’t make) in medicine. Sometimes the cost is minimal, even negligible and other times the cost is significant and worth a longer discussion.

I call Mrs. S back into the office to talk about her recent cholesterol results. They’re fairly high this time, in fact the numbers are higher than they were 6 months ago. She knows that I am going to talk to her about starting a cholesterol lowering medication because I had already warned her 6 months ago that if her numbers did not improve with her diet changes, we would have to do something. She has a strong family history of heart disease and she also is already taking a medication for high blood pressure. She comes prepared with her defense.

Mrs. S: “Dr. Cardona, I’ve done some research on cholesterol medications and I don’t think I want to start any right now. The side effects really worry me.”

Me: “Really? The side effects? You know that the side effects of muscle related pain and increased sugar levels are quite low relatively speaking.”

Mrs. S: “Well… still, I don’t want to chance it.”

Me: “… but would you rather chance having a cardiovascular event? Your cholesterol levels are very high. I can use your cholesterol results and calculate that you have a 16% risk of having a cardiovascular event (coronary or stroke death or non-fatal heart attack or stroke) in the next 10 years based on your labs and blood pressure and age. So, sure a statin MAY cause muscle aches but that might be the cost of reducing your risk of having a heart attack. Nothing is free in medicine. Every decision has a cost.”

I have this type of conversation all day, everyday. Some of my friends wonder if I ever get frustrated when patients just don’t agree to what I recommend. Sometimes I do but most times I don’t because it’s not my job to tell a patient what to do. It’s my job to help a patient understand all of the information, untangle the chaos and make an educated, informed decision that is in their own best interest. Because it’s not my cholesterol. It’s not my heart disease. It’s not my 16% risk. BUT, it IS my medical degree, my four years of medical school, my three years of residency, and my 12 years of clinical practice from which the patient is seeking advice.

“Do I really need to have a mammogram every year? Isn’t that a lot of radiation?” Me: “No, it’s really not. The amount of radiation in a single mammogram is a tiny fraction of what you would be normally exposed to in your natural environment. Nothing is free in medicine but that cost of early detection of breast cancer is small.”

“Dr. Cardona, I’m not getting my flu shot this year. I just don’t really feel like I need it. I am pretty healthy. The only time I’ve ever really gotten sick is right after getting a flu shot a few years ago so I just don’t feel like it’s really worth it. I’ll just take my chances.” Me: “Well, that’s really only part of the reason to get a vaccination. We would encourage you to get a vaccination to protect yourself against a certain disease, in this case against the influenza virus, but the second part of the reason is for herd immunity. We encourage those who are healthy enough to get vaccinations to get them in order to protect those who are not healthy enough to get vaccinations. The theory is that if a high enough proportion of the population are immune, the majority will protect the few susceptible people (the young, the elderly, the immunocompromised) because the virus or pathogen will be less likely to find a susceptible person. So choosing to not vaccinate yourself not only increases your risk of infection, but increases someone else’s. Nothing is free in medicine. Every medical decision has a cost.”

For every benefit there is a risk. For every yes there is a no. For every why there is a why not. For every action there’s an equal and opposite reaction…. wait, that’s Newton’s third law of motion. Anyway, the point is medical decisions aren’t simple, even when you think they are. Over the counter ibuprofen has risks to your stomach and kidney. Sweet sweet honey can give babies botulism if you give it to them before the age of 1. Can birth control pills cause weight gain? Maybe. But so can an unintended pregnancy. Ultimately, every medical decision is always yours (or ideally it should be). With the help of your physician or medical provider, your medical decision should be well informed and educated. What is the risk (cost)? What is the benefit (reward)? Which means more to you? What are you willing to pay? What’s your price? Nothing’s free.

“Summer sunset”. Acrylic. I painted this in the middle of December. I should title it “Wishful Thinking”.

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