Playing roulette with your physician

Playing roulette with your physician

Summary: A visual tool developed at UCLA might help patients to choose between several medical treatments. It displays the risks and benefits of different options in the form of a roulette wheel. Once the patient spins the wheel, he can see if a particular treatment will be good or bad for him. Brilliant idea!

TOPICS: Health

A recent issue of PLoS Medicine describes a visual tool that might help patients to choose between several medical treatments. This aid to informed decision making, developed at UCLA, displays the risks and benefits of different options in the form of a roulette wheel. Once the patient spins the wheel, he can see if a particular treatment will be good or bad for him. The process of shared decision making is not new, but instead of being offered probabilities and numbers, this tool offers a visual help to patients. But read more before playing roulette for a better health.

Here is an introduction from PLoS Medicine.

The researchers, led by [UCLA physician] Jerome Hoffman, show how the roulette wheel could help a healthy 65-year old man decide whether or not to be screened for prostate cancer (the screening test is a blood test called the PSA).
By spinning the roulette wheel, the man sees that if he decides to get a PSA test, he may slightly lower his risk of dying from prostate cancer but he also greatly increases the chances of becoming incontinent and/or impotent from prostate cancer treatment. The roulette wheel shows him that his chances of developing symptoms of prostate cancer are very small, whether or not he gets screened.

And as an image is better than a thousand words, the figure below illustrates what the patient could see in this particular case (Credit: Jerome Hoffman/PLoS Medicine).

Detection of a signal in a background of noise #1

This second figure shows the relative risks associated with a hypothetical treatment (Credit: Jerome Hoffman/PLoS Medicine). The roulette gives a clear warning: without treatment, the patient will die. I guess I'll choose the treatment in this particular case.

Detection of a signal in a background of noise #1

But in more ambiguous cases, how this roulette wheel will help patients to take better decisions?

One of the problems with shared decision making, they say, is that physicians have traditionally presented the risks and benefits of different treatments in the form of numbers, which many people have trouble understanding. "It is hard for anyone to comprehend the difference between a 7% chance and an 8% chance," they say.

For more information about this visual tool, the research work has been published in the PLoS Medicine journal under the name "The Roulette Wheel: An Aid to Informed Decision Making" (Volume 3, Issue 6, June 2006).

Here are two links to this paper in text format and in PDF format (6 pages, 603 KB). The above illustrations come from this paper which also warns about some limitations.

It is possible that for some patients magical thinking could be applied even to the roulette wheel, such that they would believe that the outcome they obtain on a sample spin (or series of spins) in a physician's office would predict what will actually happen to them should they choose to follow such a strategy "in real life." It is also possible that other patients will object to using the roulette wheel because of religious (or other) objections to "gambling." For both these reasons, it will be important for physicians to emphasize that the tool is designed only to demonstrate the likely potential hazards of alternate strategies.

Finally, if you want to discover more, you can try an online version of this roulette wheel.

Sources: PLoS Medicine news release, via EurekAlert!, June 12, 2006; and various web sites

You'll find related stories by following the links below.

Topic: Health

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  • Cool. Nice try in the right direction...

    Thanks for the tip, Roland! It's nice to read something about the use of computers out of the IT field.

    After reading the article "The Roulette Wheel: An Aid to Informed Decision Making", I think Hoffman, et al reviewed all the pitfalls of the "shared informed consent" (very misleading term, by the way) and offered a very nice solution to a single dimension of the problem.

    The problem they are solving is: how to explain the patient the benefits and risks in an easy way. For most geeks, probability is not that hard, but you will be surprised how much people have problems understanding what is probability, what does it mean "25% probability of survival at five years", "30% better than placebo", and things like that. Maybe you wondered why most statistics books start with lame-looking examples like flipping a coin.

    So, a visual aid it's kind of cool.

    And who said this roulette is only for the patient; it looks like a good tool for the physician too.

    I can tell you that most MDs have problems understanding the numbers we read in med books and medical journals. Most just get the "xx% will suffer yyy", "xx% will survive yy years", "xx% will develop yyy", etc. But, how do those numbers apply to the patient in front of me? Will this patient be on of those long-term survivors or will die in six months? How do I know? Of course we have tools to estimate that for a particular patient, but most doctors won't use them (because of lack of skills or lack of knowledge or simply because no enough data exist on the subject).

    I think the effort was good and in the right direction. Shared decision making have lot of problems but I think someday we will get it right. And I think it will be like this example, with the aid of computers to help you out in deciding the best treatment according to your body, your disease, your plans and your personal values.

    For those interested in the stats of medical survival estimation (or any medical statistic, really), I suggest "The median is not the message", by SJ Gould, available at several places (like for an opinion on the distorted ideas we can get when reading the cold numbers.


    • Thank you for the input


      Thank you for your long explanation. And also for pointing us at SJ Gould's work.

      Roland Piquepaille
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