Book Review
Deciding Factors
Physician authors explore the complexities behind patients’ medical decisions.
By Charles R. Meyer, M.D.
Making decisions is so easy these days. To pick a restaurant, look at the best restaurant issue of Mpls-St. Paul Magazine. To choose a movie, see whether Roger Ebert gave it a thumbs-up or thumbs-down. To choose the best route, go to Google Maps. For patients needing to make a medical decision, things aren’t so simple. Choices rarely boil down to thumbs-up or thumbs-down and options seldom can be neatly ranked. We physicians are charged with helping patients chart their journey, but finding the right way can be perplexing for both doctor and patient. Although Boston oncologist Jerome Groopman and endocrinologist Pamela Hartzband’s book Your Medical Mind: How to Decide What Is Right for You is written for patients, it holds sage advice for physicians as trip planners.
To understand how patients make important medical decisions, Groopman and Hartzband conducted extensive interviews with patients wrestling with medical problems. Most were well-educated, thoughtful people who tackled problem-solving aggressively. I would place the medical dilemmas they faced—including prostate cancer, breast cancer, hypercholesterolemia, and end of life—on my Top 10 in terms of the most difficult to counsel patients about. In all of these situations, right answers are elusive and decision-making about care is arduous.
Groopman and Hartzband tap psychological theories and mathematical models to explain why patients choose one path over another. The patient, they note, is a complex human package with pre-existing biases and fears. Some are “minimalists” who walk into the doctor’s office wanting to do as little as possible and hesitate to try something new (“the devil you know is better than the one you don’t”). Some search for the “natural” way, shunning chemicals and the high-tech answers of modern medicine. Some come in prepared to believe what the doctor has to say—“blank slates” on which physicians can write the answer; others are born doubters, ready to reject whatever is offered. Each mindset will drive the search for a solution and shape the eventual decision.
Also influencing a person’s choice are stories, leading to what Groopman and Hartzband identify as “availability bias.” They write: “Certain tales and testimonials, especially those that are dramatic or unusual, become firmly imprinted in our minds; we remember them easily, and they are readily ‘available’ to us when we ponder difficult choices in anxious moments.” The authors tell the story of a patient with prostate cancer who calculated, analyzed, listed, and explored all alternatives only to be swayed by the story of a fellow prostate cancer patient. They contend that “availability bias is perhaps the most powerful and prevalent force shaping how patients initially assess their options.” Drug companies capitalize on the power of the anecdote in direct-to-consumer ads, as “they frame information about benefit in the most favorable fashion and exploit the power of availability bias using carefully crafted images and anecdotes.” Good PR people know how to tell a convincing story.
Even when patients look at statistics, it is stories that are important. The authors quote mathematician/writer Howard Gardner, who explains: “All of us respond most profoundly to stories; they echo in our minds and become imprinted in our memories. Ultimately, we want numbers and graphs to tell us a story—a story where we can imagine ourselves as the central character.”
Curiously, for two physicians at an academic medical center, Groopman and Hartzband distrust the current trend of universally applying statistics when choosing treatments for patients. They are concerned that statistically driven guidelines rigidly dictate treatment, resulting in “a creeping paternalism on the part of health care policy makers and insurance companies to standardize care based on guidelines.” Groopman and Hartzband’s approach is the antithesis of paternalism.
The authors quote a physician who notes that “caring for people is all about negotiation,” negotiation that takes time and a sensitivity to whom you are talking. As Groopman and Hartzband write, “There are no shortcuts around serious, time-consuming, and emotionally charged conversations between the patient, loved ones, and doctors. ... Such conversations do not follow one script and sometimes take sharp detours. But repeated communication can bring clarity to the complex choices that all of us may one day face.”
In the end, the physician doesn’t drive patients to their destination or tell them the best route; instead, he or she shows them the map, tells them about the rough roads, and stays with them as they decide how to make the journey. MM
Charles Meyer is a practicing internist and editor in chief of Minnesota Medicine.