How to Talk to Doctors: Groopman and Hartzband Answer Your Questions

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. 

Leave A Comment

Comments are moderated and generally will be posted if they are on-topic and not abusive.

 

COMMENTS: 9


  1. Olli M says:

    This business of your “medical mind” sounds a bit fishy to me. When choosing between different treatment options, each will have an expected value and variance (like everything else in life). In the case of blood pressure medication, I guess that not taking it has a better expected value but higher variance, so taking the medicine is like buying insurance.

    I don’t think wanting to be proactive or not liking to take medications should have any effect on the doctors recommendation. He should tell which option has the highest expected value; then if the variance is too high he can offer less optimal choices with smaller variance.

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    • yad says:

      The problem with this is that there is no single dimension along which to measure expected value or variance. Perhaps “on average” a treatment will reduce pain but make it impossible for the patient to ever run again. This might be a very high expected value for a sedentary 70 year old, but a very low expected value for a member of the Kenyan olympic marathon team.

      The point being, most serious medical procedures involve tradeoffs that carry costs and benefits in different aspects of life. Only the patient can evaluate how these tradeoffs should be weighted given his or her specific goals and lifestyle.

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  2. rageon says:

    As a lawyer, I found interesting the question regarding doctors asking patients what to do and the resulting answer as to levels patient autonomy. There are numerous lawyers who believe (and professors who teach) that you should never tell a client what to do, but rather give them the options and +/- and ask them what they want (the “client-centered” approach).

    I always thought the opposite — assuming people paid a lot of money for expertise and expected a lawyer to tell them what to do. But really, there are clients who want that, and others who want someone with a different approach. And that’s something that can be determined very early and a client can decide whether to find someone else or not.

    However, that doesn’t always work in the medical field. Health plans limit one’s options greatly. Even if you can change providers, it’s often within the same facility — and let’s be honest, people stick up for their co-workers if you question them, which can result in worse overall care from the new provider, unfortunately.

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    • Enter your name... says:

      My health insurance plan doesn’t limit my options. I can pick any healthcare provider I want in my state. My co-pay doubles for a small number of them, but I’m not limited to certain facilities. Additionally, I can see any provider that I want if I choose to pay for it myself.

      Perhaps what you mean is, if you (or your employer) *voluntarily* choose to limit your options by selecting a limited HMO-type plan, and if you further *voluntarily* choose to limit your options to those that your insurance will pay for, then your options are limited.

      But this is a bit like complaining that if you voluntarily choose not to attend to law school, then the mean, old, nasty government “limits” your ability to become an attorney.

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  3. Travis says:

    Some of this is kind of questionable, and much of it feels as if the answers are weaseled out of in a “buy our book fashion.” Particularly the first question.

    If I ask a doctor what they would do, I want to know specifically what they would do, and why. I doubt I would get a straight answer though. I expect I would get something more along the lines of how each person has a different set of medical expectations, just like the answer here.

    With that said, there is significant evidence that Doctors often take different courses of treatment than patients, frequently foregoing care or taking on more risk to avoid side effects, while doctors are more likely to suggest lower risk – higher side effect procedures to patients.

    There are all sorts of skewed incentives in the medical profession, and maybe I’m the only one, but I think doctors could use a little more transparency. Hard to get that when you’re charged $500 for a 15 minute chat with a specialist though.

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    • Alex says:

      If doctors recommend weight loss but remain fat, I don’t know that we need to hypothesize “skewed incentives” as an explanation. Doctors are human. They don’t eat what they should. They skip medications with high side effects even if they think those medications are the right answer. They miss appointments. Ask what a doctor would recommend for a loved one, not what they actually do themself.

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  4. Skip Montanaro says:

    > This medication would reduce her risk of a heart attack by 30%.

    These risk measures are statistically derived, aren’t they? If so, I don’t see that you can state a statin would reduce a particular patient’s risk by 30%.

    Apologies if I’m being picky. I’ve been reading “Thinking, Fast and Slow.” I’m trying to get my System 2 to the mental gym more frequently than normal.

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  5. Ken Arromdee says:

    I think the answer in the tubal ligation example is that doctors have to make some decisions on a statistical basis and just because *you* did not regret it doesn’t mean that there isn’t a high probability that patients in that situation would. If the doctor agreed with you, you personally would be better off but his patients, on the average, would be worse off. He has no way of knowing ahead of time that you are a statistical anomaly.

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  6. Brian Gulino says:

    I’m a cancer survivor, proactive in my own treatment plan. My own experience is that Doctors use too many euphemisms for “I don’t know”. In the above Q & A for example:

    “this is an excellent question”
    “what is right for one is not right for another”
    “an interesting question”
    “there is considerable controversy”
    “the subject of [fill in the blank] is a controversial one”

    You listen to your patients, you make a recommendation, you explain your reasoning, then you listen some more.

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