At Friday's Medical Grand Rounds at Johns Hopkins, Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP, of Beth Israel Deaconess Medical Center and Harvard Medical School talked about what patients can do in their own interests when doctors disagree. Because doctors do disagree, they took pains to assure us, referring to the headlines of contemporary controversies: statins for primary prevention, to take one example; or prostate cancer screening, not to mention mammograms. Their talk was a short version of the argument in their book from last year.
Even if doctors do disagree, it wouldn't be so complicated if we could just (just!) figure out what patients want. Once we had that settled, we could calculate the expected utility of each possible medical decision, maximize that utility, and go home satisfied.
Unfortunately, while health economists make much use of the quality-adjusted life year (QALY) as a way to incorporate supposed universal estimates of relative utility into medical decision-making, the assumptions that go with this are hard to swallow, as Drs. Groopman and Hartzband pointed out. First, our preferences are not static but dynamic. We might want one thing one day, and something completely different the next. That's called "changing your mind."
Second, people find it very hard to predict how they might react to situations in the future. You were in an awful accident and cannot use your legs. How many years of your current, completely healthy life would you trade off in order to avoid that existence? The very question assumes that the quality of a paraplegic's life is substantially less. But people with chronic medical conditions realize that doctors, and healthy people, underestimate the quality of such a life (one example here).
Drs. Groopman and Hartzband's talk, meant as an approach to such concerns, was well presented and thoughtful, but lacked a big piece of the puzzle. Their idea is this: every patient--actually, every human being, doctors included--operates in the framework of a limited number of "mindsets" when it comes to medical decision making: trusting medicine versus being doubtful of it; supporting technology versus preferring natural approaches; and wishing for maximalist versus minimalist interventions. These mindsets can help us figure out what patients really want, as opposed to the QALYs which some health economists find very useful and others (to quote Kahneman) compare to the ether beloved by physicists in the 19th century: a poor approximation to the complicated facts of life, the variegated experiences of real patients.
The big piece I found missing goes under a name that is not beloved by today's science and medicine writers: emotion. Where do these mindsets come from? Do they always apply? And--from a broader outlook--are we really able to lay every problem, disagreement, or complication in medical decision making at the feet of cognitive biases?
Biases explain quite a bit, but it seems intuitive and accepted, even, by many scientists--that decision-making is bound up with emotion. It is popular to discuss medicine, and society in general, in cognitive terms. But not everything is cognitive or can be forced into the boxes of its science.
How do we understand our emotions, both those of physicians and patients, and how they affect medical decision making? Is it okay to rely on narrative, personal experience, fears, and suspicions when decisions have to be made? Are cognitive biases always bad, and is cognition the be-all and end-all of health care?
I am writing a book on this topic which will come out in 2013, but the short answer is No. Details forthcoming.
There was another missing piece in Drs. Groopman and Hartzband's lecture. They are right, of course, about doctors' disagreements with regard to cancer screening--they are legion. At one point, however, they threw up their hands: Every group of doctors has their own mindset. The USPSTF is minimalist, the urologists (say) maximalists about PSA testing. Everyone has their own cognitive bias and there's no right answer.
This is true as far as it goes. Yes, there's no universal answer to many deeply rooted medical controversies. But I firmly believe that there is a right answer for any given patient, according to his or her preferences, mindset, and yes! emotional needs in the context of the doctor-patient relationship.
Cognitive biases are not the answer; there is no one right answer, but emotion and communication can help us get closer to the variety of solutions necessary for the wide range of people and their medical problems.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.