For centuries human evolution has centered itself within the concept of survival and betterment of life. As a result, He has made astonishing progress. Also, within the process human being has been able to direct his achievements quite efficiently towards safety, validity, and cost of rendering medical services. Despite all the efforts, one thing seemingly has been lost in the continuum, and that is the concept of factual weighing risks against benefits of the medical intervention.
The concept of Risk-Benefit Ratio
By definition, the benefit is a valued or desired outcome; an advantage. The risk is the probability of harm or injury (physical, psychological, social, or economic) occurring as a result of participation in treatment. Both the probability and magnitude of possible harm may vary from minimal to significant. A Risk-benefit ratio, on the other hand, is the ratio of the risk of an action to its potential benefits. The risk-benefit analysis is an analysis that seeks to quantify the risk and benefits.
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The risk-benefit ratio in medicine is the cornerstone of clinical judgment as every physician continuously weigh the risks against the benefits of a particular treatment or intervention during clinical evaluation. Therefore, the clinical decision may vary from patient to patient even among those who carry the same diagnosis. This is the standard by which every physician is trained by, abide and practice according to the Hippocratic Oath. Despite all that mentioned, over the last century, the true meaning of risk-benefit ratio has been inevitably influenced by a number of determinants that has little to do with the practice of authentic medicine. The trend was pretty much the consequence of overtakes of public health and healthcare in general by the government administrations in the form of progressive micromanagement, over-regulation, excessive protocols, and bureaucracy, hence personalized medicine was gradually replaced by Officialdom of population health Care delivery model.
Although the risk-benefit ratio has been pragmatic under the population health, beneath certain circumstances such as immunization, preventative medicine or end of life care it has encountered certain obstacles. Such as entire citizens of a community have been forced in one way or the other to receive vaccinations to prevent a communicable disease or hard-pressed to take statins medications for cardiovascular event prevention. The Recent outcome has been a number of backfires by a group of activists in protest of questionable efficacy and risks involved with administering such treatments. One of the most recent controversies pertains to the correlation between autism and vaccination in children, which could be effectively unraveled by the personalized approach. Indeed, it would be premature to blame the entire trend on population health since as citizens become more educated, free flow of information becomes readily available and healthcare hits the political grounds, patients developed greater expectations. Patients today are more vigilant and are making extra educated decisions than ever before. Every so often they demand additional guarantees. Today, the era of trusting all the decisions in the hands of physicians and government agency is obsolete.
We are living in an era when consumerism has matured beyond boundaries of commodities and services well into the healthcare arena, nevertheless, politics and legislatures have been invariably evolving by compelling the healthcare delivery in the conflicting direction. For the sake of argument, let us dive into ARRIVE, ASCEND and ASPREE trials. The recent contribution of the ARRIVE, ASCEND and ASPREE trials provides useful insight into the role of aspirin use for primary prevention in the modern era. It was recently recommended narrowing its use to the highest-risk populations, including individuals aged 40 to 70 years old without diabetes with 10-year ASCVD ≥20% or patients with diabetes. Another instance is an indication to prescribe statins cholesterol-lowering medications where indications have been controversially narrowed despite overzealous side effects. Or, diagnostic threshold criteria for Hgb-A1c have been lowered for diabetes and pre-diabetes. Under the Personalized Healthcare delivery model, the majority of the controversies would be archaic.
Advancement of technology, knowledge, and emergence of modern consumerism
We have made enough advances in technology and literacy to be able to reintroduce modern personalized medicine into physician practice. Hence, it is time to put a collective approach to offering vaccines aside and focus on individual indicators and personal preference. It must be the standard of care to disengage from inflexible guideline centered medicine and boost incorporating personal determinants of health and wellness.
What we witness today is the clear example of clatter between social expectation and the healthcare delivery system. Consumeristic attitude is higher than ever. Value-based care is dominating the trade market of which by no means healthcare is immune. Nevertheless, current values are not the outcome of the true individual response to treatment, feedback, and retort. It is somewhat a product of cookie cutter protocols developed under collective corporate inspirations. Under corporate medicine, consumerism is likely to overlook the personalized risk-benefit ratio where patients are no more than numbers and as physicians’ robots. With corporate medicine, every citizen would be mandated to receive immunization or face consequences. Diagnosis of diabetes and pre-diabetes will depend on the selected level of HGBA1C dictated by cooperative protocols, influenced by financial incentives.
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Based on population health protocols, guidelines and standards have served to a degree in reducing costs, improving public health as a single unit through funneling a defined treatment to a defined population with a high percentage of success providing the treatment options were unconditionally accepted by the constituents of its community. It has worked relatively well for countries throughout the economic development phase. Nonetheless, as societies reach the point of higher economic eminence, individual knowledge and expectation begin to govern the healthcare delivery stage. Protocols and standardizations are useful to minimize legal implications, maximize insurance carrier profitability thus only at the expense of the genuine personalized delivery of medical care.
The advent of population health has created safe havens for the defective business of medicine henceforth failure to implement risks-benefit ratio in every clinical setting. Creating guidelines for treatments sponsored by prejudiced entities would yield a significant return on investment for corporations and concomitantly save money for others- a perfect niche for corporate monopoly.
Politics around healthcare, population health, and its failures
Moreover, the Politics of healthcare around the aforementioned delivery has not been much of an advantage, as it has created a perfect environment for bigoted initiatives. Certain healthcare related controversies such as Abortion, Right to try or End of life decisions have turned into political issues where it can be effectively evaluated and spoken to by personalized approach. Drug advertisements, medication labels, government mandate have generated a significant challenge for guideline-based medical care. As it necessitates adverse reactions to be disclosed for the same vaccine that may be mandatory by law, despite the fact that creates substantial reluctance from some members of the community to consent to such treatment, even if benefits of such treatment may outweigh its risks.
We are living through an information-rich period when access to data resources has become as easy as the click of a mouse. Contained by the available information patients will obviously learn about the risks associated with every treatment option. Therefore under the group healthcare delivery model, it is expected to witness a certain level of resistance concerning immunization. Managed care systems were also established based on mentioned collective concepts, as patients shall receive what the system sees fit, but not necessarily what patient and physician determine as the best treatment option-Only to satisfy the lean business delivery model irrespective of the personal values.
Risk-Benefit Ratio and Avoiding Tunnel Vision
One of the most important factors in avoiding tunnel vision in the practice of medicine is the application of risk-benefit ratio on every single patient visit treating every case as unique and every patient as a textbook who needs to be studied before applying the best clinical judgment. Unfortunately, this seems to have changed as well. Whether by means of increasing government mandates or through the culture of guidelines and protocols established by a group which was originally intended to maximize the quality of care but also foreseen as an efficient tool to practice defensive medicine in a highly politicized and lentiginous industry. Therefore following cookie cutter path has become inside the box approach for many practicing physicians.
Risk-Benefit Ratio and Value of rendered Medical Service
In order to determine the value of a medical service rendered to a patient as it implies to value-based reimbursement, it is crucial to factor in the risk-benefit aspect of the treatment applied within the context of such service. Conversely, current values are generally set by social, demographic, population determinants, and the group of accepted guidelines which precludes individual variations. Under such criteria, benefits may outweigh the risk for the general population but then again not necessarily for few members within that community.
As per Public health has been defined as the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals then again the individuality of its approach has been the subject of scrutiny. For that reason, healthcare has experienced a number of backfire with regards to the legitimacy of public health recommendations-such as anti-vaccination movement. There is no doubt that the role of public health includes utilizing strategies to ensure the safety of others while respecting individual choice and need.
Freedom of Information, knowledge base and importance of risk-Benefit Ratio
Freedom of information has led to an increasing trend in the diversity of opinion and knowledge base. It is a common practice for a patient to search the internet for risks of a given procedure or side effects of medication. Vaccines are not exempted from this practice. Raw Information whether reliable or not will open new doors to questions. Every person will have a personal perception of what the collected information and the personal approach by the physician will be even more important.
Patients level of education is the perfect predictor of how the person is engaged in his daily health, and at what level his risk factors are stratified for a given medication, treatment or procedure Vs. it benefits. The worst knowledge is incomplete Knowledge. Patients entering the exam room with no prior research in reference to his problem will probably freely accept the cookie cutter healthcare approach. Social norms and practices have a significant impact on the patients’ perception of medical intervention and the multitude of factors within itself will drive the quality of care delivered at a personal level.
Every physician is aware of the importance of establishing realistic expectations with patients. As there is no risk impermeable treatment option. As a matter of fact, side effects may be even harsh Nevertheless, under certain individual circumstances acceptable. Such as one of the biggest concerns about vaccination today is their probable potential to cause autism in children. The argument for or against such speculation is a clear example of failing risk-benefit assessment, population approach and guidelines. The human being is a social presence and the social factors always need to be factored in during the clinic visit. If a patient lives in a heavily populated urban area the chance that he may acquire measles is probably high enough to outweigh the risks associated with vaccination. In contrast, if a patient rarely traveled and lives in the rural community that may be of lesser of the concern.
Every patient has the right to choose but it is just as important to ensure the safety of others perhaps, through transparency around vaccination status to avoid transmission of communicable disease to others. Every individual has the right to choose but responsibility toward respecting the rights of others. The responsibility is enforced through proper accountability. Personalized medicine is the solution to solve the growing conflict between healthcare delivery, the practice of medicine, patient expectations, and true value-based reimbursement.