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.


Caleb b

As previously poor and uninsured, I found it extremely obnoxious that doctors could not give me any indication of how much something would cost BEFORE the visit. My solution was to ignore whatever condition I had until it became an emergency. I knew that they couldn't turn me away and that I wouldn't pay any bill I received.

My question: was this the correct strategy? If it is not, what should I have done given that doctors don't give prices before treatments? I understand it depends on the condition, but how about for a variety of conditions: possible flu, severly injured ankle, extreme back pain, strange growth on skin. The goal is to #1 get treatment #2 pay as little as possible for that treatment.

Alternative question: my wife and I want to start a family but I don't want to pay the thousands of dollars to go to a hospital to deliver it. I told her that we can walk in with no ID and refuse to identify ourselves and the hospital will deliver the baby but won't/can't charge us. Will this work? Or will the hospital keep our baby until we identify ourselves?

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Enter your name...

Leaving aside the moral problems of your premeditated theft of services, it won't work. The hospital won't keep the baby, but they'll call child protective services, who will. Additionally, how do you expect to get a birth certificate for the child, if you won't give your name?

Instead, you should look into charity care programs, midwives, and (assuming a low-risk pregnancy) home birthing, all of which are less expensive than hospital births.

The way to find out how much a medical service will cost is to call the clinic's business office, not the doctor. They can't make binding promises (just like an auto mechanic can't promise that his initial estimate will completely fix everything on your car, because he might discover a second problem while fixing the first), but they can tell you the price of any office visit or procedure you care to ask about.

Enter your name...

How do you decide, when the decision isn't entirely biological?

Here's a scenario: A BRCA2 mutation gives a woman a 50-50 chance of having breast cancer by age 70 and a 15% chance of ovarian cancer. Each of her children has a 50-50 chance of acquiring that damaged gene, with its risk of aggressive breast, ovarian, prostate, and other cancers, from her. It also, unexpectedly, means that each pregnancy *increases* the carriers' lifetime risk of having breast cancer, especially in the two years after each pregnancy.

So from a purely biomedical perspective, women with BRCA2 mutations should have no children at all: each pregnancy slightly shortens their lives.

But is it desirable for a chance of a biological effect to trump the certainty of a psychosocial effect? How does one decide how much weight to give to the biological vs the non-biological?

(Commenters, please don't bother saying that all women with BRCA2 mutations should "just adopt": not only is that more expensive and difficult than most working-class or middle-income people can manage, but reputable adoption agencies require adoptive parents to have a normal expected lifespan, which excludes cancer survivors and people at high risk for developing cancer.)

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Hexe Froschbein

I think that such people should qualify to have a surrogate paid to carry their babies. In the UK, the NHS should be picking up the bill for that, in the US and elsewhere I don't know, but creating life is as useful as is preserving it and in this case, we'd do both.

It's no different to any other disability that needs a community to help out with and for a change, it's also problem that can be solved with just throwing money at it.

Caleb b

Another question: will the medical industry ever get to the point where I only get one bill and it's what I'm actually supposed to pay?

I hate receiving separate bills from the hospital, doctor, anesthesiologist, x-ray technician, parking lot attendant, cafateria cashier, etc....

Why can't I get one bill, for everybody, and it be correct the first time they send it?

Also, why aren't hospital bills required to tell you what each item on the bill is? I don't know what SRQ Test #25 is!?! Why did I need it six times? Tell me what it is and why I needed it!

Sorry, rant I know.

Jason

Why can't I simply call my doctor directly?

My wife's a medical assistant, so I know physician's workloads are high, there aren't any insurance reimbursement codes (yet), etc. Calling a nurse, who sends a message to a secretary, who passes it on to the doctor, who may or may not call back the same day seems so ridiculously inefficient. God forbid someone's on vacation; you may never hear back. Every other profession seems to function just fine with voicemail and e-mail.