How Patients Think

Recently, I had a conversation with Shannon Brownlee (the widely respected science journalist and acting director of the Health Policy Program at the New America Foundation) about whether men should continue to have access to the PSA test for prostate cancer screening, despite the overwhelming evidence that it extends few, if any, lives and harms many more men than it benefits. She felt that if patients could be provided with truly unbiased information and appropriate decision aids, they should still be able to choose to have the test (and have it covered by medical insurance). Believing that one of the most important roles of doctors is to prevent patients from making bad decisions, I disagreed.

After reading Your Medical Mind, the new book by Harvard oncologist and New Yorker columnist Jerome Groopman, I think he would probably side with Brownlee’s point of view. Groopman, whose authoring credits include the 2007 bestseller How Doctors Think, and wife Pamela Hartzband, MD have written a kind of sequel to that book that could have easily been titled How Patients Think. Drawing on interviews with dozens of patients about a wide variety of medical decisions – from starting a cholesterol-lowering drug, to having knee surgery, to accepting or refusing heroic end-of-life interventions – the authors explore many of the factors that influence people’s health-related choices. The result is a compelling narrative that seamlessly blends “rational” factors such as interpreting medical statistics and decision analysis with personal factors such as past experience, emotional states, and personality styles.

Some of the ground in the first few chapters (“Where Am I In the Numbers?” and “Believers and Doubters”) has been well-covered in other recent books, notably, in H. Gilbert Welch’s Overdiagnosed and Know Your Chances. But Groopman and Hartzband go farther in challenging two notions that have strong advocates among current U.S. health reformers: 1) adherence to evidence-based guidelines is a panacea for improving care outcomes; and 2) preparing meticulous “advanced directives” will simplify and improve end-of-life decisions. The authors also observe that shared decision-making means just that: a shared decision by a doctor and patient on a level at which a patient feels comfortable, not the one-sided ritual of “obtaining consent” or complete abdication of responsibility by the doctor.

“If medicine were an exact science, like mathematics,” Groopman and Hartzman conclude, “there would be one answer for each problem. Your preferences about treatment would be irrelevant to what is ‘right.’ But medicine is an uncertain science. … The path to maintaining or regaining health is not the same for everyone.” Even to a physician who spent several years of my career working on prevention guidelines and remains an unabashed supporter of guideline-driven care, these words ring absolutely true.

In practice, of course, patients make a lot of seemingly irrational decisions. A healthy 40 year-old male patient may, if he wants, request annual PSA tests and decline the HPV and influenza vaccines for his children. These are poor choices which some doctors would even take personally. As his doctor, and a believer in the mantra of shared decision-making, I would do my best to make sure that he understood the relevant statistics, and elicit any past experiences or personal beliefs that prevented him from considering my recommendations. But if he persisted, suggest Groopman and Hartzband, I would at some point need to stand aside and recognize the limits of persuasion and my comprehension of his motivations. It’s a very hard thing to do. Which brings me to a last point: although Your Medical Mind was written for patients, doctors will find it worth reading, too – if only for the opportunity to get inside the heads of patients and find out what they were really thinking.

Kenny Lin is a family physician practicing in Washington, DC. He is an associate editor of the American Family Physician journal and teaches family and preventive medicine at Georgetown University School of Medicine. You can follow him on his blog Common Sense Family Doctor, where this post first appeared.

8 replies »

  1. I have a friend who was recently diagnosed with stage I breast cancer and has experienced surgery and is now beginning chemotherapy. My conversation with her several days ago impressed me very much. She told me that it took her a full 3 days to understand that she herself had cancer and to accept that a connection now existed between a vocabulary related to cancer and her real life. Even after she achieved this understanding, she remained quite affected by the cancer vocabulary and its connection to her. For example, when her doctor told her that she had a 85% to 95% chance to become a cancer survivor, she was stunned and asked him, “Wait a minute, are you talking about cancer survival? Does that mean that I have a chance not to survive?” When her nurse told her that she was fortunate to have the cancer detected at such an early stage compared with other patients, my friend was angry and pointed to her own eyes, which were already filled with tears and said loudly, “Keep talking that way; I know I am lucky, but I just can’t control this….” To be honest, as an oncology nurse scientist, I saw nothing wrong with what her doctor and nurse had said. Although I can explain my friend’s anger as denial or as some other kind of normal emotional response from being a newly diagnosed cancer patient, I was shocked by my friend’s strong response. This shock has helped me to reconsider how a cancer patient may think and how understanding may help achieve what Dr Peabody was referring to as caring for patients.

  2. The problem is healthcare is Marcus Welby died and went to heaven. Our first family physician delivered babies, performed surgery, treated pneumonia and performed well child visits. He knew the medical histories, family dynamics and socioeconomic status of his patients. These days, I doubt that my physician even knows my name without looking at my record.

  3. first of all thank for sharing such a good information with us. another thing after reading this article i have buy the book. i have read it complete. greate.

  4. Enjoyed it, my cousin bought me a copy of that book and it was a very good read, although I disagree with a lot of her points there.