Medicine
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.
- How Care Teams Can Support Shared Decision Making In Primary Care (1 Of 2)
Earlier this afternoon, I delivered the keynote speech at the Team Care Challenge, sponsored by the Patient-Centered Primary Care Collaborative, Medstro, and the American Resident Project. This is the first of two posts containing...
- Psa Screening By The Numbers: No Benefits, Many Harms
Previous studies found that two-thirds of men who receive prostate-specific antigen (PSA) screening for prostate cancer didn't have shared decision making with their physicians. If shared decision making occurred at all, patients were more likely...
- Conservative Medicine: The Big Idea (and Title) Of My Book
A few days ago I was reminiscing about my family medicine residency, where at one of my outpatient training sites I provided care to Amish patients in rural southern Lancaster County, Pennsylvania. The Amish didn't believe in checkups and rarely visited...
- Rethinking Shared Decisions In Prostate Cancer Screening
Last October, the U.S. Preventive Services Task Force provisionally recommended against screening for prostate cancer using the prostate-specific antigen (PSA) test, eliciting a variety of reactions from medical and patient advocacy groups. The New England...
- Improving Your Understanding Of Health Risks
When there is a plane crash in the news, my mother-in-law, who dislikes flying anywhere but has driven coast-to-coast many times, says that she will never get on a plane again. But according to the National Center for Health Statistics, the odds of being...
Medicine
Book Review: "Your Medical Mind" and the challenge of shared decision-making
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.
- How Care Teams Can Support Shared Decision Making In Primary Care (1 Of 2)
Earlier this afternoon, I delivered the keynote speech at the Team Care Challenge, sponsored by the Patient-Centered Primary Care Collaborative, Medstro, and the American Resident Project. This is the first of two posts containing...
- Psa Screening By The Numbers: No Benefits, Many Harms
Previous studies found that two-thirds of men who receive prostate-specific antigen (PSA) screening for prostate cancer didn't have shared decision making with their physicians. If shared decision making occurred at all, patients were more likely...
- Conservative Medicine: The Big Idea (and Title) Of My Book
A few days ago I was reminiscing about my family medicine residency, where at one of my outpatient training sites I provided care to Amish patients in rural southern Lancaster County, Pennsylvania. The Amish didn't believe in checkups and rarely visited...
- Rethinking Shared Decisions In Prostate Cancer Screening
Last October, the U.S. Preventive Services Task Force provisionally recommended against screening for prostate cancer using the prostate-specific antigen (PSA) test, eliciting a variety of reactions from medical and patient advocacy groups. The New England...
- Improving Your Understanding Of Health Risks
When there is a plane crash in the news, my mother-in-law, who dislikes flying anywhere but has driven coast-to-coast many times, says that she will never get on a plane again. But according to the National Center for Health Statistics, the odds of being...