Medical decisions — tradeoffs, emotions, preferences and experts

Maybe you wonder why I, a cardiologist, writes about vaccines and mammography.

It is because I have grown intensely interested in the medical decision. As a doctor in a preference-sensitive field, electrophysiology, how do I help patients understand and choose the best path–of which there are many. This seems like a simple task, but with humans, it is not. Especially these days, when we choose from so many tools.

Many forces play on the act of deciding on action or inaction. There is how I feel as a doctor about the risks and tradeoffs. That’s important because we influence decisions based on how we present the choices. There is how the patient understands risk, or perhaps better said, feels risk. Then there is the balance between what clinical science and population statistics say versus what is right for the person before our eyes in the exam room.

I often tell patients things like, “AF gets most dangerous when doctors get involved.” Sure it’s hyperbole, but it’s true in many ways. A patient recently said to me right after I recommended a risky but beneficial procedure: “but I’m alive right now doc.” My wife Staci says seeing things–as in the ability to see frailty, futility and death as normal–can sometimes be a burden for caregivers. “You get it now, and there’s no going back,” I heard her say at a hospice and palliative care lecture. Indeed it is easier to adjust diuretic doses and follow guidelines than it is to discuss the big picture with people. Stepping from the crowd of bystanders is no small thing for a caregiver.

Recent guidelines in cardiology have rightly emphasized patient preferences in choosing a path. That’s a good development but it doesn’t mean clinicians should leave complex decisions up to patients as if it were a menu. More times than not, after my session at the whiteboard explaining absolute risks and benefits, a patient says, “Ok doc, what do you say I do?”

The thinking about the act of action or inaction is why dilemmas like screening mammography and vaccine decisions interest me.

Recently, my friend Dr. Lisa Rosenbaum wrote this terrific piece, Invisible Risks, Emotional Choices — Mammography and Medical Decision Making, in the New England Journal of Medicine.  I tweeted the link as soon as it came out. A few strong voices in social media complained that the powerful words were hidden behind a paywall. Lisa went to the editors of the NEJM and presumably asked nicely, and voila, the essay is now available for free.

Must-read is an overused term these days, but this one is truly a must read. I’ve read it three times already.

The purpose of this blog is to help. Lisa’s essay does that.

JMM

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