How Doctors Think, shaped my thinking as a practicing primary care doctor on the importance of language and the potential pitfalls we make in reaching decisions. I always recommend my medical students read that book.
Unfortunately, his latest work fell quite short of my expectations. In it, the authors try to understand and create a framework on how patients reach decisions about their medical care. In the end, this was a book about human psychology wrapped in the doctor patient relationship. Nothing particularly earth shattering here.
The real question I had is who is responsible for helping patients avoid these cognitive and psychological errors? Patients or doctors?
They note how the mindset of patients can be divided into the following categories – “believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation.” Specifically, some patients want maximal treatment and others believe “less is more”. To avoid cognitive traps, the authors recommend that data be viewed in both positive and negative forms. Telling a patient that a therapy has side effects for 10 percent of patients is very different than saying 90 percent of patients have no side effects.
Other tips to good decision-making included minimizing emotion before deciding, bringing a friend or family member to an appointment to provide additional eyes and ears, and also getting second opinions. Finding a doctor who provides “shared medical decision making” might also decrease the chance of making a choice only to regret it later. In the book, many patients moved beyond decision paralysis upon hearing a story of another patient with a similar illness and predicament. Specifically, patients realized that instead of focusing on the negative, like the side effects, focusing on the positives and the ability to adapt made all the difference. There is both power and potential pitfall in hearing other patient’s stories, which may be anecdotal.
Dr. Groopman and Dr. Hartzband noted that patient decision making and autonomy vary depending on circumstance. Sometimes patients want full control. Other times they wish to cede it to physicians, hence the reason many want to find the “best” physician. Surrogates, who act on behalf of patients when incapacitated, are ideally supposed to use “substituted judgment” and choose treatment based on what the patient would have wanted. Like patients, however, surrogates too will change their mind or relinquish or reclaim autonomy depending on the situation. As a result, sometimes doctors use the principles of “beneficence”, the principle that physicians should act in the patient’s best interest, and “nonmaleficence”, to do no harm.
Physicians can also unwittingly bias a patient’s decision by recommending a “best” treatment and downplaying others, which could be a better match for the patient’s preference. Although there is a movement in health care to provide treatment which is evidence based, the authors conjecture that this focus would result in doctors recommending treatment not in preference of a patient. These seems rather ludicrous as already many current guidelines are not being followed.
The authors conclude that patients are best served if they find doctors who do not superimpose their preferences while at the same time don’t simply rubberstamp what you want. “A doctor who facilitates but also may challenge your decision process sometimes gives you more.”
Completely agree. Perhaps this book is best suited for doctors. While the book may be an enlightening read for patients, there isn’t necessarily an easy practical framework which will help them make the right decisions.