Doctoring Knowledge

Medical decisions — tradeoffs, emotions, preferences and experts

Maybe you wonder why 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 or 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.


3 replies on “Medical decisions — tradeoffs, emotions, preferences and experts”

Thank you Dr. John. The article you cite toward the end of your column by Dr. Lisa Rosenbaum is exceptionally well written – and truly MUST READ material. It provides a highly sophisticated and insightful look at how not only medical (but also life) decisions are made that is invaluable to clinicians (providing insight on why patients select action or inaction) – and ALSO to patients (on the various manners in which different clinicians may present these available options for action or inaction). THANK YOU!

I found 2 things interesting about Dr. Rosenblaum’s article. The first was her example of a woman with no family history of breast cancer. Eighty percent of women diagnosed with invasive breast cancer have no family history of breast cancer. The second is the assumption of over treatment of breast cancer. Until 2010 biomarkers that would indicate which woman diagnosed with DCIS would go on to develop invasive breast cancer so every woman was treated. It will probably be another 10 years before those biomarkers are taken into account in the decision of which women to treat.

A great many Americans – including more than a few physicians and other anointed experts – respond to statistics that might challenge their current beliefs not just with rejection but with rage and accusations of evil intent. Decision-making is always partly emotional, and (contrary to what the essay perhaps implies) it should be – it’s been shown that purely rational decision-making (possible only to the brain-damaged) is inferior in practice, and our emotions reflect our deeply held values even when those values cannot be articulated in a way that satisfies a science-centered (or medicine-centered) worldview. However, our culture has turned into one that seems to recognize no underlying consensus reality, but only a cloud of differing beliefs whose holders consider themselves under no obligation to accept a common ground of semi-objective facts. For so many, the scientific data, individual experiences, historical events, even people they don’t like or don’t want to believe in simply don’t exist, and pointing them out just places you among the reprobate (perhaps this is a descendant of our ancestors’ Manichaean religious attitudes?). The healthist view would say our obesity epidemic is our biggest problem; we have a national epidemic of cognitive and spiritual dysfunction that’s going to destroy us a lot faster if we’re not lucky.

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