Last week, we solicited questions for Harvard physicians Jerome Groopman and Pamela Hartzband, the authors of Your Medical Mind: How to Decide What Is Right For You. They’ve come back to us with some answers. As always, thanks for your questions, and thanks to Jerry and Pam for taking the time to answer them.
Q. Is it reasonable to ask a doctor: “What would you do in my case if this was happening to you/your child/your parent?” -VBinNV
A. This is an excellent question that patients frequently ask us. We point out in our book that each of our mothers had a different “medical mind” so the recommendation would be different for each mother. What is right for one person is often not right for another. For example, someone who is a maximalist wants to be very proactive, ahead of the curve and do everything possible to address a medical problem. A minimalist prefers the minimum amount of medication, “less is more.”
Q. 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”? -James
A. An interesting question. Much of medicine exists in a grey zone where there is no one right answer about when to treat and how to treat. That is why you need to figure out what applies to you and what doesn’t and how you weigh risk and benefit.
Q. My friend’s blood pressure is only slightly high. What is the benefit of taking blood pressure medice for borderline high blood pressure? 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? - Eric M. Jones
A. As it happens, this was exactly the dilemma faced by Alex Miller, one of the patients in our book. He also had a mild increase in blood pressure and had side effects from the medications that were prescribed for him. There is considerable controversy about when and how to treat mild elevations in blood pressure. Interestingly, in Europe the guidelines are quite different from the guidelines in the United States. The question “is it worth it?” is exactly the right question to ask, and can only be answered by the individual.
A similar situation happened to Susan Powell, another patient in our book who was deciding whether or not to take a statin medication for elevated cholesterol. This medication would reduce her risk of a heart attack by 30%. But Susan found that a woman like her with a cholesterol level of 240 mg/dl had a risk of a heart attack over the ensuing 10 years of 1% (1/100). She decided not to take the medication. She was a minimalist and for her, the risk was not worth it. But another patient with the same cholesterol level decided to take the statin, because she was a maximalist and felt that she could be the 1% who risked a heart attack.
Back to your friend – there are reliable risk calculators for hypertension and cholesterol on the internet. But getting the numbers is only part of the answer. Your friend then needs to understand his own medical mind, how he balances the risks and benefits of treatment.
Q. Seventeen years ago, I requested that my obstetrician 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.”
Seventeen 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. -Ann H.
A. You knew your medical mind, but perhaps could not explain it clearly to your doctor. This is a very common problem and in fact, we have experienced it ourselves when we were patients. We have found that the new terms we present in our book can help patients more effectively communicate their thinking, and also help them to understand the doctor’s mindset.
Q. 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? - Alan
A. The subject of diet and weight loss is a controversial one. We do not give specific medical advice, but it is likely that there is not one “best” diet for everyone. You may need to try several different approaches to see what works for you.
Q. Doctors asking me what I would like to do next is my pet hate. 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 ;-( -Hexe Froschbein
A. Different patients want different degrees of autonomy. Some patients want the doctor to make the decision for them while others want to make the decision entirely on their own. Most want to share the decision-making process with their doctors. In our book, we cite several studies that confirm this diversity with regard to autonomy. In your case, you might wish to tell your doctor that you would like him or her to state their recommendation before asking your opinion. However, a final decision will require your input because it is you as the patient who will enjoy the benefit or suffer the complications of any therapy.
Q. 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.) – Anonymous
A. We address the issue of BRAC testing and its consequences in our book. DNA findings alone do not settle the issue of what to do – it is a difficult and individual decision. Different women make different choices depending upon how they weigh the risks and benefits. In addition, there is always an interplay between genes and environment that can modify risk as well as new options for reducing the risk of cancer. We wish you the best in making this decision.
Q. 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, cafeteria 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! -Caleb b
A. We agree completely! Dealing with these multiple and sometimes inaccurate and confusing bills is a waste of time, energy and money for everyone.