How to Make Tough Medical Decisions? Bring Your Questions for the Authors of Your Medical Mind

What do you do when the medical experts disagree? Should you have that PSA screening, or mammogram? Should you really be taking statins — and what about vitamins? On these and many other medical issues, consensus is hard to come by; individuals end up weighing the benefits and risks.

Jerome Groopman (more here) and Pamela Hartzband have written a book to address this conundrum, called Your Medical Mind: How to Decide What Is Right For You. The authors are both Harvard physicians, and they are also married to each other. To write the book, they interviewed a variety of patients with different medical problems, including those from various socioeconomic, religious, and cultural backgrounds. Along the way, the authors identified all sorts of different mindsets — proactive vs. passive, “believers” vs. “doubters,” and so on. They synthesize what they learned into a framework meant to help any one person try to figure out what’s the optimal treatment. Along the way, the authors ask a variety of tricky, compelling questions: how much autonomy do people really want in making treatment choices? How to deal with the regret of making a choice that turns out to be ineffective? Why do “living wills” so frequently fail to predict a patient’s actual end-of-life desires?

Groopman and Hartzband have greed to field questions from Freakonomics readers, so fire away in the comments section. As always, we will post their replies in short course. Here, to prime the pump, is the table of contents from Your Medical Mind:

  • WHERE AM I IN THE NUMBERS?
  • BELIEVERS AND DOUBTERS
  • BUT IS IT BEST FOR ME?
  • REGRET
  • NEIGHBORLY ADVICE
  • AUTONOMY AND COPING
  • DECISION ANALYSIS MEETS REALITY
  • END OF LIFE
  • WHEN THE PATIENT CAN’T DECIDE

This post is no longer accepting comments. The answers to the Q&A can be found here.


VBinNV

Is it reasonable to ask a doctor, "What would you do in my case if this was happening to you/your child/your parent?"

Sarah

Of course that is reasonable. No question is ever without reason when you are trying to figure out what is the best course of action... and if you are truly stuck and do not know how to navigate, it is reasonable to expect your doctor to help you.

Stephen

My diet is quite poor, but not terrible, but i have no realistic chance of improving it. Is investing in taking a multivitamin every day a good idea, given I do not have much income? Which one? Thank you!

Adam

How much power to patients really have? And is it based on money, social status, ability to 'play the game'? Where does it leave the hippocratic oath?

Patrick

Most health care practitioners are trying to work with you to find a solution, regardless of money or social status. Patients can always refuse a test or procedure that they feel is unnecessary.

Eric M. Jones.

1) My friend's blood pressure is only slightly high. What is the benefit of taking BP meds for borderline HBP? The doctor put him on one and then another. The first made him cough uncontrollably, the second gave him vicious diarrhea. It this worth it?

2) What's the chance for a cure for my friend's depression in the near future?

James

Given that the placebo effect is real, even when the participants know that they're receiving a placebo, how can we really say anything with medical "certainty"??

Also is it more important to eat a diet where calories in <= calories out or is it more important to consume all of the "must" foods (these seem to change daily but things like sardines, pomegranates, blueberries, oatmeal, yogurt, green tea, etc). So if you've hit your calorie requirement for the day is it better to stop or to eat that bowl of oatmeal that has the necessary nutrients but will put you over your daily calorie "limit"?

Rob

Are there any commonly prescribed drugs, treatments, or procedures that stand out as being particularly wasteful, unnecessary, or harmful?

Patrick

Arthroscopic surgery for osteoarthritis of the knee. (See JAMA Mosely 2002.) Cutting off little bone spurs makes no difference in terms of pain or function.

Why is it still reimbursed?

Kyle

If more people got what they really wanted from the health care system, would it end up costing us more or less than we're currently spending as a nation?

vimspot

Atul Gawande spoke of end of life care in
http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all
He mentions research that shows on average, hospice care did not decrease patient lifespan for ~5k Medicare patients with terminal cancer or congestive heart failure. For certain conditions, hospice care actually extended life ("pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months").
Are patients presented with this type of information when making these difficult decisions? Is the standard of care to pursue hospice care when the data suggests it extends life? If your'e the patient or patient's family, it would seem that if the choice were presented as purely personal, pursuing aggressive treatments would have the rhetorical advantage ("of course we're going to fight this") unless framed properly.

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Ann H.

17 years ago, I requested that my OB perform a tubal ligation when my second child was born when I was 29. I KNEW I did not want more children, ever. He refused, saying, "Oh, you'll change your mind." "NO I WON'T." "Well, we won't do that because you might change your mind."

17 years later, I have spent god-knows-what on birth control because my doctor didn't believe I knew my own mind.

If this book tells you how to make doctors do what you want instead of what they think is best for you, I'm all for it.

Alan

What should I do when medical experts disagree about what course of action is best? For example, one of several reasons that I am having trouble losing weight is that different experts, many of whom are physicians, disagree about what sort of diet best promotes weight loss. I don't know which diet to follow so I don't follow any diet. How can I figure out which diet advice is best?

Hexe Froschbein

Ask to see the efficacy figures for the advised diet, ie. how many people lose weight following it, and how many people are still keeping it off 5 years later.

a humble bokonist

1) what are your views on the medical basis of drugs like antidepressants and antipsychotics? Do you agree with Marcia Angell who took on a lot of "respected" doctors (even from harvard: here is the link- http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/?pagination=false ) and said that there is a very weak medical and cost-benefit basis for giving out psychiatric drugs?

2) What do you think of the influence that medical companies are having on doctors doing research and diagnosing patients?

3) Are you aware of facts (like change in cataract procedures and unnecessary dentist fillings?) like a lot procedures and prescriptions are unnecessarily cooked up where doctors can make more money? If so, would you in all honesty agree that the hippocratic oath is garbage and doctors like everyone else like us are influenced by incentive?

4) What are your views on bokonism as alternative medicine? (just kidding!)

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Jarjar

Doctor in training here...why doesn't everything in a hospital or a clinic have a price tag attached to it? We're always just ordering things willy-nilly for patients but I know if we told them how much it would cost them before handing over the prescription, they would be willing to try diet and exercise some more before opening their wallets.

Hexe Froschbein

Dear 'Doctor in training'

your advice sounds great in theory, but unfortunately 'dieting' does not work in the long term for the vast majority of patients and the so the advice to 'lose weight' is unhelpful quackery.

Don't believe me? Go hunt for the studies that show that diets work with an acceptable failure rate and see for yourself. Would you prescribe a medicine that has an almost 100% failure rate in the long term? Of course not. Diets are no different, and it's actually even worse because you're messing with patients psyche here and inducing guilt trips and causing them to believe that being sick is 'their own fault'.

Hexe Froschbein

Doctors asking me what I would like to do next is my PETHATE.

Unfortunately, this is a newfangled bad habit and almost every consultation leaves me making 'decisions'. And that is before I even consulted a second opinion...

How can I know? I didn't study medicine, so there is no way I can make an informed decision and I don't see a point of paying megabucks to a specialist just to be asked to do their job in the end.

Because when I go to 'inform' myself, I inevitably end up on the interwebs which is less useful than a dice throw -- could have saved myself the money in the first place and just come up with my own DIY quack method :( (maybe we should all take the free Stanford Anatomy course and put the doctors out of business...)

As a final piece of wise advice... if I end up with two quacks disagreeing with each other, I usually ask a third, because it's always good to have an extra opinion... ;-(

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frankenduf

i dont have time to read the whole book- i just need to know one thing- should i go down fighting, or should i just let it go?