by Yeong Sek Yee & Khadijah Shaari

The authors, Dr Jerome Groopman, MD and oncologist together with his wife, Dr Pamela Hartzband, MD and an endocrinologist, are both on the faculty of Harvard Medical School and also on the staff of Beth Israel Deaconess Medical Center, in Boston,USA. They also wrote “HOW DOCTORS THINK.”

This book explores medical decision-making and emphasizes the role of various biases that affect our decisions, usually unconsciously. Even the youngest among us have had to make difficult medical decisions. Perhaps we’ve had to choose between two doctors with very different opinions, or decide whether to treat a condition with a pill or with diet, exercise and natural remedies. Some of us have had to make even bigger decisions and help loved ones do the same.

In a country (US) where medical treatment is seldom free and often expensive, deciding how to treat a health condition can be nearly as taxing as the condition itself. Adding to the pressure is the fact that many of us are seen by doctors who don’t have the time to properly help us weigh our options.

This is further compounded by the fact that, “despite many scientific advances, the unsettling reality is that much of medicine still exists within a gray zone where there is no black and white answer about when and how to treat. Often there are several differing approaches to treatment, each with its own risks and benefits. The best choice for an individual may be anything but simple or obvious.”

The quest of the authors is to shed more light on how our minds approach medicine and, using real patients’ stories, to help us make appropriate choices when it’s demanded of us.  The authors’ own philosophy is borrowed from the early 20th-century physician Sir William Osler, who believed that “when trying to unravel a complex medical diagnosis, you should listen carefully to the patient, because he is telling you the answer.” In other words, Groopman and Hartzband’s desire is for doctors to be more patient, and for patients to be better informed.

According to the authors, the mindset of patients can be divided into the following categories – “believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation.”  Briefly, these are explained as follows:

• Believers approach their options with the sense that there is a successful solution for their problem somewhere. A believer can have strong naturalism orientation, trusting in the healing power of nature and shunning high-tech interventions. Or a believer can have a technology orientation, relying on the promise of modern medicine. A believer who is a maximalist feels that more treatment is the best approach and doing less is shortsighted, whereas a believer who is a minimalist is certain of the opposite strategy. 

• ·Doubters approach all treatment options with profound skepticism.  They are deeply risk-averse, acutely aware of potential side effects and limitations of drugs and procedures. They question how much benefit a therapy really offers them and whether there might be deleterious consequences. Doubters are typically minimalists.
•  A naturalism orientation or naturalism bias holds the notion that the body can often heal itself if given the proper environment, harnessing the mind-body connection and supplementing with herbs, vitamins, and other natural products. It is the firm belief that there exists smarter and safer ways to prevent and treat illness without resorting to synthetic solutions.
• On the opposite end of the spectrum is the technology orientation, the belief that cutting-edge research yielding new medications and innovative procedures holds the answers.

Our backgrounds predispose us towards taking varying general approaches to making decisions, such as:

• A minimalist who holds to the notion that “less is more,” that risks and unintended consequences may over shadow apparent benefits.
• A maximalist who believes that more treatment is the best approach and doing less is dangerous.
• And a pragmatist who chooses from the whole range of treatment options as each particular situation warrants.  

The authors also introduced several other concepts to help patients decide…such as “health literacy, availability bias, framing, numbers needed to treat, number needed to harm, net benefit and best practice.” We shall briefly explain these concepts:

• “Health literacy” means understanding statistics and the risks and benefits of a treatment.
• “Availability bias” is the most powerful and prevalent force shaping how patients initially assess their options. Certain tales and testimonials, especially those that are dramatic or unusual, become firmly imprinted in our minds; we remember them easily, and they are readily “available” to us when we ponder difficult choices in anxious moments.
• “Framing” is a key aspect of health literacy—knowing how the same information can be presented as either positive or negative. For example, stating that 35% of people with a serious illness are cured by a certain treatment has a hopeful resonance, while stating that 65% of people die despite that therapy has a pessimistic sound. But both statements are factually correct and describe the same data. For that reasons, it is always valuable to “flip the frame” in your mind, to view information in both its positive and its negative forms.
• In the “numbers needed to treat,” patients musk how many people with a condition similar to yours need to receive a therapy in order to improve or cure one person. For example, in A WORLD WITHOUT CANCER, Dr Margaret Cuomo, a radiologist, quoted a study that found that 2,970 women must be screened (mammography) once in order to save one life.
• Similarly, in the “numbers needed to harm,” how many people typically must receive the treatments in order for one to suffer a side effect, more clearly reveals the risk of the therapy. Decision aids often contain these numbers, or your physicians may give them to you.
• “Net benefit” means the potential gains from the treatment minus the downsides. After seeing all the data, particularly the “number needed to treat,” patients have to decide whether the net benefit is worth it.
• “Best practice”….Committees of specialists are convened to draw up guidelines that aim to identify “best practice” for a certain medical condition. The principle is that guidelines should be drawn from the “best” evidence and crafted by the “best” scientific experts in the field. These guidelines are a key component of so called evidence-based medicine, the idea that clinical practice should be based solely on the results of scientific studies. 

Unfortunately, there are a number of pitfalls that Dr Groopman and Dr Hartzbrand advise patients to be aware of:

• “Best Practice” guidelines aren’t strictly “scientific”….some experts who write guidelines are consultants to drug and device companies. Different groups of experts can disagree significantly about what is best practice.
• For many treatments there exists a substantial “gray area of indeterminate net benefit”
• Patients should be aware that doctors and experts may “frame” information in a way that reflects their own preferences. As physicians, we (the authors) have found ourselves at times too quickly telling our patients which treatments we prefer rather than working with them to understand their own thinking. Of course, patients may want, and often ask, what their physicians think is best. But that should occur after information is presented in a neutral way. 

In conclusion, the authors admit and reiterate 2 core fundamentals:

• We (the authors) believe that all patients should be fully informed about their condition and then asked about their preferences. To be truly informed, patients should be aware of the gray zones in medicine. They must keep in mind that guidelines are not purely scientific and have a significant subjective component.
• In our role as doctors, our aim is to help patients understand what makes sense for them, what treatments are right given their individual values and goals. We are especially mindful not to impose our preferences about our own health on our patients.

After reading this article, share with us who and where you are—whether a believer or doubter, a minimalist or maximalist in respect to your cancer treatment. Did your doctor guide you or did he frame you?

Watch the 2 doctors explain some of their concepts on YouTube at the following link: https://www.youtube.com/watch?v=qSrJcyeMLB0