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Drs. Jerome Groopman and Pamela Hartzband are a Longwood-style literary power couple: both on the staffs of Beth Israel Deaconess Medical Center and Harvard Medical School, and widely read in prominent publications from The New Yorker to The New England Journal of Medicine. We spoke this morning about the lessons that can be learned from the vivid stories and psychological insights in their new book.
I derived two takeaways from “Your Medical Mind.” First, you need to be aware of your own biases on medical decisions: Are you a minimalist when it comes to treatment, or a maximalist? Do you tend toward the natural or the technological?
Second, you need to understand decision dynamics that are common to all of us: Our tendency to be influenced disproportionately by what happens to people we know, for example. Our greater willingness to take a risk by not taking action than by doing something.
The federal Agency for Healthcare Research and Quality has just come out with a succinct cheat sheet, a list of questions to ask your doctor, from 'What is the test for?' to 'Are there any side effects?' I wonder if you could generate on the fly a list of the questions you should ask yourself before you finalize any medical decision?
1. What is my medical mindset?
JG: The questions you refer to from the government are generic questions, and they're valuable. But the questions you should ask yourself first are: What is my medical mind? Am I a maximalist, so I believe in being proactive, ahead of the curve, doing everything and more? Or am I a minimalist, so I believe that less is more?
And finally, are you a believer or a doubter? The believers are people who believe there's a solution to their problem and they're going to find it and go with it. And the doubters are people who worry about side effects and unintended consequences, the people who are risk-averse and worry the treatment will be worse than the disease. So that's your first question: What is your medical mindset?
2. What are the numbers?
PH: The next question has to do with numbers: Where am I in the numbers? Which numbers apply to me and which don't?
JG: When I looked at those [AHRQ] questions, they said, 'Ask your doctor about the outcomes of the surgery or treatment.; And I think what's important is that the really informed patient is aware of the fact that those numbers, first of all, may or may not apply to you as an individual, because often they come from clinical trials that don't have many women, or many elderly people --
PH: Or they don't include somebody with diabetes, or kidney problems, or other illnesses.
[module align="right" width="half" type="pull-quote"]"But the question to ask is, 'For my individual case, what is the likely outcome if I do nothing?'"[/module]
JG: And also, how the numbers are framed is really important. Drug company advertising is obviously framed in a way to make the benefits seem maximal, and often the way we hear information on the Internet or in the newspaper or from other sources is: 'This reduces your risk by 30%,' and that sounds like a major impact.
But the question to ask is, 'For my individual case, what is the likely outcome if I do nothing?' And that gives you the starting point, and then you can assess how much the impact of the drug or surgery may have on you, with that understandable bit of information.
It puts it into the right context of whether your initial chance of a heart attack or a stroke or whatever might be so extremely low that 30% of a very, very small number is still very small. It's like the woman we describe in the book whose chance of a heart attack is 1 in 100; that's very different from an overweight man who's already had a heart attack, is a smoker and has high blood pressure.
[module align="right" width="half" type="pull-quote"]'You may be disappointed but not racked with regret.'[/module]
3. What is influencing me as I decide?
PH: And the third question would be: Are there outside or inside influences that are impacting me that I haven't thought about?' And the biggest one is other people's stories, what's termed by psychologists as 'availability.'
If your Aunt Susie has a terrible side effect from a particular medicine, you won't want to take it. But you need to integrate that information into the numbers: How common is that side effect? Did she have some other reason to have that side effect that doesn't apply to you?
And conversely, if somebody you know or heard about had a fabulous result from a particular surgery, you may be dying to get that surgery, leaping forward, but maybe you should hold back a little and find out how likely that fabulous outcome really is.
Part of what I came away with from 'Your Medical Mind' is that the gray areas in medicine are so huge that even if I do my very best to make a good medical decision, I may still end up — my word, not yours — screwed. I could have a bad outcome. Can you help me with that? Is it all about just avoiding later regret?
JG: That's a really important point. You can have an incredibly competent surgeon and wonderful attentive nursing in an excellent hospital, and an honest surgeon will tell you, 'I can do everything right, and the hospitalization goes perfectly, and the outcome is still not good, the person is left with pain and irritation.'
We show this quite vividly in the book with Lisa Norton and Carl Simpson, two people having surgery, elective surgery but for really bothersome orthopedic problems of the type very common among baby boomers.
Carl is disappointed that his knee still has limitations and discomfort, but he has no regrets because he didn't make the decision blindly and he followed a process that was true to his medical mind. While Lisa, who also has an unsatisfactory outcome, is not only disappointed but just filled with regret an self-blame, which is an enormous burden.
And I can speak to that personally because I made a really bad decision with my back. I was having a lot of back pain and I didn't really go through a process that allowed me to step back and not just give my maximalist believer mindset free reign. And I've regretted it, and I've learned from it, but I've learned from it a very hard way. So I think that medicine is uncertain, and there is this very large gray zone, and anyone who guarantees, like a recent insurance company ad — 'You know you'll have the right outcome' — that's just not true.
PH: You can't guarantee a good outcome.
JG: You can be confident that you went through the right process, and the decision was right for you, and you may be disappointed but not racked with regret. That's one of the goals of the book.
Note: You can read an excerpt of "Your Medical Mind" on NPR books here. And the authors are scheduled to be featured tomorrow on Radio Boston between 3 and 4 p.m.
This program aired on September 22, 2011. The audio for this program is not available.
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