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?

Enter your name...

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.

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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regretful bokonist

sorry, i was a little hasty in my questions...i had never heard about you guys before (this just means i'm totally ignorant about medicine) and just checked your profiles and now realise that you aren't new kids on the block, but old hounds and have sufficient grey hair (not Pamela) to make question 3 irrelevant and seem stupid. So i'll cancel out 3 and ask you 3' instead:

3') what kind of incentive structure for doctors will make them give out diagnosis, procedures, and prescriptions which are in the best interest of the patients and not the medicine companies funding them?

correction for 4):

4) What are your views on bokonism as the guiding principle for medical philosophy?

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'.

helm

Right now we subsidize obesity through corn subsidies and through the billions and billions of dollars of research into late stage interventions to save people from highly preventable conditions like CHF and diabetes. If we put a tiny amount of that money into research into how to change people's diets from a highly processed high protein diet into a mostly plant based real food diet and public health campaign, if we paid doctors to try to influence their patients, we would see cost savings and life savings.

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?

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.