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Patients Are Their Own Reward

October 11, 2012 By:
Masha Rifkin, JNS.org
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Perhaps doctor doesn’t know best.

In their new book, Your Medical Mind: How to Decide What Is Right for You, husband-wife physician team Jerome Groopman and Pamela Hartz­band lay the groundwork for making sound medical decisions.

No choices are completely independent, the authors say; rather, they are influenced by a set of values and history. Understanding what makes people tick is vital in making the correct medical decisions for them.

“We’re all just flooded with information about health and conflicting advice from experts,” says Groopman, who is an oncologist and chief of experimental medicine at Beth Israel Deaconess Medical Center in Boston, and writes on medicine and biology for The New Yorker.

“We wanted to write the book to give people the framework — the tools — to make the best choice for themselves.”

The authors offer four main categories that people tend to fall into when it comes to medical bias: technology orientation (people who believe that the best treatments lie in cutting-edge research or new procedures); naturalism orientation (people who feel that the body can heal itself if supplemented by herbs and other natural products); maximalists (who believe the more treatment the better); and minimalists (less is more).

There are also the believers and the doubters. Believers have faith that a solution for their problem exists, whereas doubters view all treatment options with skepticism. Some of us are risk averse, while others are more prone to taking risks.

The categories aren’t necessarily linear, but it is important to understand where a person falls in order to gain more clarity and control over decision-making.For instance, naturalists can be maximalists — think of that friend that takes every known herbal tea and vitamin.

Hartzband, an endocrinologist at Beth Israel Deaconess Medical Center and Harvard Medical School, emphasizes, “Doctors as well as patients have these mindsets.” So, if a doctor is a maximalist, he may be prone to recommending more treatment than necessary. In order to assess your own, and your doctor’s, biases, the authors recommend that you inform yourself and build your “health literacy.”

“What does it really mean to be informed?” they write. “It means knowing the numbers about a particular medication or procedure, its likely benefits and side effects, but it also means being alert to how the presentation of these numbers can confuse or mislead you.”

In order to illustrate their point, the authors present the case of Susan, a generally healthy woman who discovered she had high cholesterol. Her doctors recommended she take a statin, a very common drug, but Susan — a minimalist and a naturalist — decided to do her research first. After speaking to a friend, Susan discovered that statins could have a side effect of muscle pain. When she voiced this concern to her doctor, he emphasized that that side effect seemed relatively insignificant compared to the 30 percent reduction in risk for heart attack over the next 10 years if she were to take the drug.

Susan returned to her research, went online and calculated that given her age, cholesterol number and lifestyle, her risk for having a heart attack in the next 10 years was only 1 percent. She decided not to take the drug.

Susan’s process, the authors describe, is reflective of a few key ways to get informed. The No. 1 factor influencing preference, they say, is stories we hear of people in similar situations. The authors caution that these stories also have the potential to distort our vision “by making the rare appear routine.”

Susan learned of the potential side effects of statins from a friend, and it affected her decision. Nowadays, many of the stories we hear come from the Internet. According to Hartzband, the availability of these stories can be beneficial, but also misleading. “The Internet has lots of excellent information, and there’s also a lot of misinformation; you have to figure out how that information applies to you and doesn’t.”

Another way to build our health literacy is to research the numbers and statistics. The authors particularly advocate learning the “number needed to treat.” This is the number of people that need to be treated in order to cure one person. They also advocate “flipping the frame” — or seeing information in both positive and negative forms.

Armed with this information, the authors argue, you’ll be in a better position to make a well-informed decision.

A final component the authors note is the “focusing illusion,” one’s tendency to focus on how a part of our life would be affected by a particular side effect of a treatment. In doing that, people fail to see how adaptive one can be to living without perfect health, Groopman argues.

Various models now ask people to place a value on different aspects of health: sight, sexual potency, etc. However, Groopman says that it is nearly impossible for a healthy person to really imagine what life would be like without those things, so placing a value on them is irrelevant.

For those facing these choices, Hartz­band suggests finding someone similar to you, someone who is living under the conditions you are concerned about, and to see, as best you can, if you can imagine yourself in their position.

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