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.

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  1. VBinNV says:

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

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    • Sarah says:

      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.

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    • Patrick says:

      Yes, very reasonable. Health care is moving from a completely paternalistic philosophy (doctor decides, patient complies with this decision) to one where patients usually have much more choice. Much of health care should involve dialogue between practitioner and patient, as age, past medical history, and present condition should not decide treatment alone. Sometimes patients get “too much information” (from health care providers, internet, etc) and need help weighing this information.

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    • Enter your name... says:

      Yes, you can ask, but you shouldn’t expect to get an honest or accurate answer.

      The same doctors who routinely recommend aggressive treatment to their patients routinely refuse such treatment for themselves. When doctors are diagnosed with advanced cancer, they don’t die in the ICU after months of horrible treatments. They die at home, surrounded by family and in peace, having known from the beginning that a 5% chance of survival wasn’t worth the 100% chance of misery.

      I believe that the difference is that they have seen the misery repeatedly and know about all of the possible complications, and they actively choose “dignity, peace, and quality of life” over “treatment and its many complications”. We patients, on the other hand, know nothing about the daily reality, so we’re choosing between “treatment and being a ‘good’ patient” or “nothing”.

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  2. Stephen says:

    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!

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  3. Adam says:

    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?

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    • Patrick says:

      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.

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  4. Eric M. Jones. says:

    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?

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  5. James says:

    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"?

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  6. Rob says:

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

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    • Patrick says:

      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?

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      • Enter your name... says:

        I think it’s interesting that most podiatrists long ago stopped doing the equivalent surgery for bone spurs on the heel, but it’s just been impossible to convince most surgeons that removing bone spurs in the knee only benefits the X-ray, not the patient.

        If I were in charge of a health insurance company, I’d stop paying for this surgery, or at least start informing patients that we expected it to have zero net benefit.

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  7. Kyle says:

    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?

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  8. vimspot says:

    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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