When faced with making a difficult decision about medical treatment for yourself or someone else, are you more of a “Do everything possible” type or a “Less is more” type? Would you rather be treated with the newest prescription drug or a dietary supplement that you think is “more natural?”
The answers reveal a few aspects of your unique “medical mind,” a key theme of the sixth annual Stephen E. Straus Lecture in the Science of Complementary Health Therapies. The lecture by Drs. Jerome Groopman and Pamela Hartzband on “When Experts Disagree: The Art of Medical Decision-Making” honored NCCIH’s founding director.
Groopman and Hartzband, an oncologist and endocrinologist respectively and a husband-and-wife team, are on the faculty of Harvard Medical School, where Groopman is Recanati chair of medicine and Hartzband is assistant professor of medicine.
They developed their concept of a medical mind—i.e., a mindset and orientation unique to every person that informs how he or she makes medical decisions—after seeing patients, colleagues and others struggle to make decisions under a barrage of often-conflicting health information, including from experts.
Drs. Pamela Hartzband and Jerome Groopman presented their concept of the “medical mind” at this year’s Stephen E. Straus Lecture.
Photo: Bryan Ewsichek
“Despite all the advances in medicine and technology, the application of scientific principles to medicine and the sophisticated data analysis that we have now, there seems to be increasing controversy among experts about how to prevent or treat even the most common conditions,” Hartzband said. “Why are they disagreeing? How do patients make their decisions in the face of this kind of controversy?”
Adding to the difficulty, recent research in cognitive science has shown that the methods for decision-making taught in medical textbooks are “deeply flawed,” said Groopman.
Both set out to study this problem further through field research: interviewing scores of patients around the United States with a wide array of backgrounds and medical problems on how they make medical decisions. Some common threads emerged to become language in a new model.
In their model of the medical mind, the so-called “maximalist” is willing to do anything it takes to achieve the best treatment outcome, while the “minimalist” thinks “less is more.” “Believers” tend to have strong faith in recommended treatments; “doubters” are more cautious. “Technologists” want the latest high-tech treatment or breakthrough and “naturalists” are more interested in options such as acupuncture, massage or herbal supplements.
These terms may be pictured as pairs of endpoints on axes, with many points in between. Not only do patients have medical minds, but also health-care providers, which affects the advice that they give, and larger entities such as committees and cultures.
So, what are people to do when they need to make a treatment decision in the context of experts disagreeing? “We think it’s essential to assess three dimensions,” said Groopman. “The starting point is your medical mind.”
The second dimension, presented by Hartzband, is the evidence—one should look at actual numbers and data and, to the extent possible, try to see how they apply to the individual. She demonstrated how the same statistics can be framed and presented in different ways, from drug ads to clinical-trial reports. “We all need to be very careful when looking at relative numbers rather than absolute ones...and making the best choice involves not only knowing the numbers but how you value them,” she said. Risk calculators on reliable web sites such as NIH’s, she suggested, help with a critical question: “What is my risk of a certain outcome without any treatment?”
Stories from other patients who were in the same medical situation, faced the option(s) we face and made a choice are the third area to assess. “In an era of science-based medicine and scientific thinking, stories are often dismissed as anecdotes,” Groopman said, adding that research by Daniel Gilbert indicates that these stories are useful in helping people choose and estimate the possible impact of an outcome on their life. One must watch for pitfalls, however, such as overestimating the likelihood that someone else’s rare side effect will happen to you.
The speakers expressed hope that their language and concepts based on field research would facilitate the process of shared decision-making and improve communication. They also urged keeping in mind that “every expert recommendation is subjective...[and] many areas in medicine fall into a gray zone where there’s not a clear right answer.”
To learn more, view the archived lecture at videocast.nih.gov.