on October 11, 2011
I looked forward to reading Dr. Jerome Groopman's new book, Your Medical Mind - How to Decide What is Right For You, co-authored with Dr. Pamela Hartzband. His previous work, How Doctors Think, shaped my thinking as a practicing primary care doctor on the importance of language and the potential pitfalls we make in reaching decisions. I always recommend my medical students read that book.
Unfortunately, his latest work fell quite short of my expectations. In it, the authors try to understand and create a framework on how patients reach decisions about their medical care. In the end, this was a book about human psychology wrapped in the doctor patient relationship. Nothing particularly earth shattering here.
The real question I had is who is responsible for helping patients avoid these cognitive and psychological errors? Patients or doctors?
They note how the mindset of patients can be divided into the following categories - "believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation." Specifically, some patients want maximal treatment and others believe "less is more". To avoid cognitive traps, the authors recommend that data be viewed in both positive and negative forms. Telling a patient that a therapy has side effects for 10 percent of patients is very different than saying 90 percent of patients have no side effects.
Other tips to good decision-making included minimizing emotion before deciding, bringing a friend or family member to an appointment to provide additional eyes and ears, and also getting second opinions. Finding a doctor who provides "shared medical decision making" might also decrease the chance of making a choice only to regret it later. In the book, many patients moved beyond decision paralysis upon hearing a story of another patient with a similar illness and predicament. Specifically, patients realized that instead of focusing on the negative, like the side effects, focusing on the positives and the ability to adapt made all the difference. There is both power and potential pitfall in hearing other patient's stories, which may be anecdotal.
Dr. Groopman and Dr. Hartzband noted that patient decision making and autonomy vary depending on circumstance. Sometimes patients want full control. Other times they wish to cede it to physicians, hence the reason many want to find the "best" physician. Surrogates, who act on behalf of patients when incapacitated, are ideally supposed to use "substituted judgment" and choose treatment based on what the patient would have wanted. Like patients, however, surrogates too will change their mind or relinquish or reclaim autonomy depending on the situation. As a result, sometimes doctors use the principles of "beneficence", the principle that physicians should act in the patient's best interest, and "nonmaleficence", to do no harm.
Physicians can also unwittingly bias a patient's decision by recommending a "best" treatment and downplaying others, which could be a better match for the patient's preference. Although there is a movement in health care to provide treatment which is evidence based, the authors conjecture that this focus would result in doctors recommending treatment not in preference of a patient. These seems rather ludicrous as already many current guidelines are not being followed.
The authors conclude that patients are best served if they find doctors who do not superimpose their preferences while at the same time don't simply rubberstamp what you want. "A doctor who facilitates but also may challenge your decision process sometimes gives you more."
Completely agree. Perhaps this book is best suited for doctors. While the book may be an enlightening read for patients, there isn't necessarily an easy practical framework which will help them make the right decisions.
on September 22, 2011
I think this book did a great job of interviewing people in various stages of medical decision-making and using their choices to show the psychology behind it. The book shows you how doctors or drug companies can sometimes push their own agenda regardless of your feelings as well as the hard decisions people make to sometimes go against what their ailing loved one wants. If you ever need to receive treatment for anything in the future, this book will help you realize the psychological aspect of your decision and may help you make the right one.
on September 25, 2011
This book has already helped me make decisions with my aging mother about her best medical options, while giving me a new perspective on taking care of myself.
The authors clearly know not only their own specialties, but the entire confusing state of today's medicine: insurance, choices, and standardized care. They're frank in their analysis and advice. I recommend this to anyone.
This book explores medical decision-making and emphasizes the role of various biases that affect our decisions, usually unconsciously. Overall, it's a pretty good book and I can recommend it, but it's somewhat heavy on narratives of case histories and light on systematic presentation of the key findings - basically opposite of a textbook and apparently targeted more at the general reader.
I personally would have preferred a more systematic presentation, but I went ahead and compiled my own summary of the key findings:
(1) In general, the findings described in the book apply to everyone involved in making medical decisions: patients, patient advocates, physicians, nurses, researchers, administrators, etc.
(2) Our backgrounds predispose us towards taking varying general approaches to making decisions, such as being a minimalist (as little treatment as possible, letting the body primarily take care of itself), maximalist (treating aggressively, including treating preventively), naturalist (favoring natural CAM treatments rather than conventional allopathic medicine), technocrat (favoring modern high-tech medicine), and pragmatist (choosing from the whole range of treatment options as each particular situation warrants).
(3) The way information is framed can greatly influence our decisions. For example, "40% of patients are cured by this treatment" sounds more encouraging than "this treatment fails to cure 60% of patients." An implication is that statistics for treatment outcomes have to be looked at carefully, and looking at only summaries of statistics can be misleading.
(4) Anecdotal cases (as reported in this book) can be informative, but they can also excessively influence our decisions (availability bias).
(5) Serious illness and strong emotions can result in poorer decisions.
(6) Recommendations of doctors can vary considerably due to biases resulting from personal background, training, institution where they work, outcomes of the patients they've cared for (again, availability bias), and the treatments they're most familiar with. An implication is that it's often preferable for patients to seek multiple opinions, though that leaves patients having to make decisions when the provided opinions diverge.
(7) Ideally, patients and doctors should work together to make decisions, but patients vary widely in what role they want to take, ranging from wanting to be in primary control (and thus doing considerable work to investigate their condition and treatment options, and possibly seek multiple opinions) to delegating all decisions to their doctors.
(8) Advance directives for end of life decisions often don't work well because (a) people have difficulty anticipating how they'll feel when the time to decide comes, so they're prone to changing their minds and (b) even if directives aren't changed, it's often not clear what decisions will best comply with directives in particular circumstances.
(9) Advocates often have difficultly making decisions on our behalf. Part of the difficulty is the tension between trying to know what we would decide for ourselves versus deciding what they consider best for us.
(10) In general, following a systematic decision process tends to reduce regret if an outcome turns out to be disappointing (can at least say that the best possible effort was made). However, this doesn't mean that decision-making can be reduced to a formulaic "by the numbers" approach, for several key reasons: (a) there will always be uncertainty and complexity, so judgment inevitably will be required, (b) biological variability among patients means that treatments need to be individualized to patients, and (c) subjective values and goals are usually involved, so there may be no objectively "correct" decision.
This book addresses the issue of how we make decisions about our medical care. Most of the book is comprised of case studies, actual patients who had to make decisions like whether to take cholesterol-lowering drugs, have knee surgery or sign do-not-resuscitate orders.
Drs. Groopman and Hartzband let the patients talk at length. Their stories are not simple tales with black-and-white answers or outcomes. The patients dither, they procrastinate, they clam up when they should talk frankly, they change their minds, they reject medical advice. Sometimes they do the right thing, sometimes they don't.
I appreciated this ambiguity. We often read medical horror stories and think, "Well, I wouldn't have made a mess of it like they did. I would have done the right thing." These stories show that the right course of action is often not clear or straightforward, and even when it is, it may be a difficult action to take, for many reasons.
Drs. Groopman and Hartzband do a fine job of identifying ways patients typically respond to medical advice, especially in the concluding chapter. You can skip right to that one, if you want: some people are believers, some doubters, some trust in natural therapies, some in technology, some people are minimalists, others maximalists. Most of us harbor some mix of these tendencies that guides our medical decision making.
I'm not sure the book addresses "how to decide what is right for you" as the subtitle suggests. I found the book to be more descriptive than prescriptive. And, I suspect that when most of us become patients we won't have the same luxury to weigh options and come to reasoned conclusions as the people in this book did. After a while, I just wanted to shout at some of these folks, "Take the pill! Have the surgery!"
But I really appreciated the End of Life chapter, in which the grey areas of treatment when nearing the end of life are fully explored. I think we tend to believe that if we just sign advance directives and health care proxies, we're covered. But the case study here shows that little by little, small step by small step, a family can be drawn into procedures and treatments they were certain they didn't want. If these case studies simply get people talking more honestly and openly to their doctors and their families, these authors will have done a great service with this book.
on November 21, 2011
I expected a more analytical, practical book. The subtitle, "How to Decide What Is Right for You," suggests something of an outline or blueprint. Instead, this small, well-written book, about 200 pages long, presents several handfuls of case studies of how apparently very sharp, apparently well-educated individuals with life/death illnesses made decisions about their medical care. We're not talking about treating the sprained ankle or sinus drainage. The physician authors, husband and wife Groopman and Hartzband, add their insights about the decision-making processes, and along the way throw in useful bits and pieces of information about the health care business complex. So, while the reader is not really given much of anything in the way of a decision-making process, he/she is still given plenty to think about by two thoughtful and caring practitioners. Surprisingly to me, money is not an object in any of the case studies, either from the standpoint of the providers, that is, doctors, hosptials, etc., (with the one obvious exception of the specialists who recommend their approach to the solution of the patient's problem) or from that of the consumer, that is, the patient and society as a whole who finance the ventures.
I've read Groopman's other books, and while it's useful to know about how my doctors make up their minds, it's much more important to me to understand the factors going on in my conscious and unconscious mind. This also applies to the people-as-patients who are close to me as they make decisions about medical treatment.
Some people are unhappy because Groopman & Hartzband fail to make the case for how to convince patients to follow the statistically best course of treatment, while missing the point that for most of our medical decisions, there may not be a "best" treatment. OK, colonoscopy is the gold standard for intestinal cancer screening. Fine. But there simply aren't all that many "best" options, and almost any medical intervention varies hugely according to patient expectations, willingness, acceptance, income, etc. etc. and so forth. The statistics about how many "best" treatments changed every year were the most interesting to me. HRT, no HRT; vitamins or not, drugs that work and then get yanked; surgeries that are found to be less than ideal. It rather strikes me that the act of believing in a "best" is possibly as irrational as any factor patients bring into the examining room.
Perhaps, if all patients truly understood statistics, we would make different decisions. Perhaps, if more doctors understood the reality of a patient's experience with a treatment protocol and how it fits into a life, they would make different recommendations. Hard to say.
My best friend is evaluating a serious, expensive, and necessary but not urgent surgery. Her family medical "story" is vastly different from mine. Reading about other people's backstories helps me get a handle on why she processes information one way, and I take similar data and go a different direction. This surgery is too new for there to be any useful "best" statistics, not unlike the chapter about making transplant decisions. Her processing is simply her way of thinking, not necessarily "full of cognitive errors." This surgery could involve input from four different specialists, at least two of whom will need to be in the OR at the same time. They make a plausible case for why each is the better expert for her problem. They have stats. However, statistics fail in an N = 1 decision, when every 1 who faces this situation is significantly different from every other 1.
Your Medical Mind is NOT a checklist, or step-by-step, or even a deliberate guide to making the "right" medical decision, primarily because there is no such thing as the "right" decision, most of the time. It's all a series of trade-offs, bartering an expected but unknown future outcome against a very present-day option. The best any of us can really do is understand what we bring to the table. I happen to think reading other people's stories as examples of their decision-making process is a pretty good way to help me think about mine. The book is also useful for directing conversation with the people in your life for whom you may be asked to make medical decisions, such as parents, partners, and children. I had not recognized how nearly completely useless my own medical directive documents are in the event of a near-death experience, and I'm (statistically) ahead of most in that I have the documents at all.
Every time I step into a medical practice, I sign a paper that says I will be, in the end, responsible for the charges if/when my insurance company is done. In the long run, I am also responsible for the outcome. Should it turn out "wrong," I may have recourse and get money, but it's still my body that's broken, and my life to rebuild after. As such, understanding my side of the decision is totally my responsibility. IMO, Groopman and Hartzband could have gone a bit farther down this path.
on October 29, 2011
As a scientist I always questioned using medications, and tried to avoid falling for drug companies' promotions. This book showed me clearly with data and statistics, when and how to take medicine when needed or recommended. The book is written for any type of reader who is interested to know more about on how to be intelligent and rational patient.
on October 15, 2011
I was disappointed with this book, and was going to award it only 2 or 3 stars. But, on second thought, I found some useful tidbits in it, and I believe that if it helps even one patient to arrive at a better choice of medical treatment, this book is well worth reading.
I won't summarize "Your Medical Mind" here, but would refer you to the excellent review posted recently by Dr. Davis Liu.
If you have time to read only one of Dr. Groopman's books, I would strongly recommend "How Doctors Think," which beginning to end gives valuable insights into medical decision making. The essential message there is that, even though nearly all doctors have the patients' best interests at heart and are fully competent in their respective specialties, doctors are likely to have some degree of tunnel vision which prevents them from tailoring the "statistically best" treatment to the individual patient. "How Doctors Think" gives the sage advice that patients are best served by being informed and proactive about diagnostic and treatment options.
on November 10, 2011
This is an excellent book in discussing how we, as patients, determine the kind of treatment we get for our diseases. It talks about the different personalities and how those types differ in how they feel about the different treatment options and so much more. It is a good companion book to How Doctors Think. As a cancer patient who has come after five times through treatment to make a role for myself in the treatment plan I found it true to personality types.