Perception of Risk

I wrote about my thoughts on risk. I believe so much of medicine is driven by a perception of risk that does not exist.

A perceived risk that drives irrational standards of care that self perpetuate themselves in a spiraling unsustainable economic death spiral.

I don't think I'm alone when I speak the truth about my own perceptions of risk. I am much more likely to view a young patient as carrying more perceived risk than an older patient. I am much more likely to view a previously healthy patient as carrying more perceived risk than one with multiple chronic medical conditions and an acute toxic surgical abdomen.

Why? Because my perception of risk has more to do with my (correct) expectation of recovery from illness than it does with the actual recovery itself. My perception of risk hinges on my expectation of recovery, not the actual recovery itself. This is a critical point to remember so let me give you two examples of patients to ponder.

1. An 87 year old Alzheimer's patient (and no other medical problems) presents with a three day history of fever, shortness of breath and cough. ED evaluation shows a BP of 85/50, HR 120, Temp 102.9, WBC 20K, Cr 4.5, BUN 110, gluc 220, Hgb 11.2, platelet count of 78K, shaking rigors and a very large RLL pneumonia.
2. A 35 year old healthy married man, gainfully employed, with no medical problems presents with three day history of fever, shortness of breath and cough. ED evaluation shows a BP of 85/50, HR 120, temp 102.9, WBC 20K, Cr 4.5, BUN 110, gluc 220, Hgb 11.2, platelet count of 78K, shaking rigors and a very large RLL pneumonia.

I ask you only one question.

1. Which patient is more risky?

The answer is neither. Practice good medicine and the risk of both patients is zero. The risk of a bad outcome is much higher for patient #1 who carries a much higher chance of death. A natural death.

However, I contend that the perception of risk is far greater for patient #2. Not because they have a higher chance of death (which they don't) but because the expectation of death and disability is far less. And therefore, any bad outcome is perceived (inappropriately) as negligence and not a progression of the disease process.

The perception of immortality lives on for the young and healthy and any deviation from that expectation is a perception of negligence and therefor a perception of risk by the physician, even if no risk exists.

Both patients presented with the exact same scenario. But I would view patient #2 as riskier (which is only perceived) every single time, in spite of patient #1 having a much higher rate of mortality based on nothing more than their age. This is what I mean by actual risk vs perceived risk.

A physician's expectation of recovery for patients of advanced age or with a heavy burden of disease is far less than young and otherwise healthy patients. Which explains why two patients with identical presentations will be triaged within the mind of the physician as having far different expectations of outcomes and by default, risk (or perception of).