Risks, Benefits, and the “Invisible Bag”


Richard F. Mitchell, MD, MS

“Did you discuss prostate cancer screening with your patient?”

“I did, but…”

“But what?”

“Well, it was strange, but as I was discussing the risks and benefits, the patient just looked at me and said, ‘This is confusing, can’t you just tell me what I should do? What would you do if it was you?’”

Has something like this happened to you while you were precepting residents? Has it happened to you when you were talking to your own patients? In this age of patient-centered care, we teach our residents to involve patients in shared decision making. How do you counsel a resident working with a patient who doesn’t want to buy into that program? How do you teach your residents to respond to the question, “If it was you, what would you do?”

You might find the answer in an invisible bag.

“There is an invisible bag right in front of you. Think ‘Santa Claus sack.’ Would you like to reach in and take something out?”

“Why would I do that?”

“It’s full of $100,000 bills.”

“Yes! Can I take two?”

“No. But there’s something else you should know. The bag also has blank pieces of paper that feel exactly like $100,000 bills.”

“That’s OK—can I put my hand in now?”

“One last bit of information before you do—it’s also full of razor blades.”


“Is there anything else you want to know?”

“How many razor blades? How many $100,000 bills?”

“These are the big questions! Some decisions are easy—10,000 razor blades and only one $100,000 bill and you’d be crazy to put your hand in. One razor blade and 10,000 bills and you’d be crazy NOT to put your hand in. But compare a poor person and a billionaire—would they put their hands in for the same risk and benefit? Would we put OUR hands in at the same time?  Why should we have the same answer to the question ‘Do you want to be screened?’ You and I may not feel the same way about the risks and benefits.”

This is the crux of the matter. Consider prostate cancer screening. How worried is your patient about erectile dysfunction? For some of my patients, if they can’t get an erection they want someone to pull the plug—they avoid screening because the risk is too great. For others, the development of ED is a foregone conclusion, so they don’t worry about it at all. Some men aren’t worried about a false positive test but are quite concerned about dying from cancer that they could have treated but didn’t because we never looked for it.

As providers, we cannot know how patients feel about the risks we present to them or how much they want the benefits we offer until we ask. We don’t know at what point they will decide to stick their hand into the invisible bag.

When I counsel residents about discussing risks and benefits, I recommend they avoid the confusion of full contact statistics by asking questions that compare potential outcomes with simpler statistics that are more accessible to the average patient. “Which sounds better—giving yourself a one in a thousand chance of preventing prostate cancer death that comes with a one in five risk of having something bad happen (from painful biopsies to uncommon heart attacks) or skipping the risk of something bad happening but losing the chance to avoid prostate cancer death?” Infographics can also be very helpful in these discussions. (There’s a great one about prostate cancer from the National Cancer Institute at http://www.cancer.gov/types/prostate/psa-infographic, last accessed January 11, 2016.)

Choosing a treatment on behalf of a patient who has asked can be expeditious, and depending on how beneficial the intervention is it’s something we should be comfortable doing ourselves (and letting our residents do). But the murkier the risk/benefit analysis becomes, the more important it becomes to have these conversations and make sure our patients are included, especially if we are choosing not to perform a service, and especially if the nature of the risks and benefits are not on the same level.

Now if only insurance companies would let me just choose a medicine for my patients without endless prior authorizations.

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