TREATMENT DECISIONS

Every day, physicians and patients weigh complex treatment decisions – decisions made more difficult when experts publicly disagree. For example, the use of cancer screening techniques including mammography and prostate-specific antigen tests have been hugely controversial in recent years. Government, research and medical specialty panels have recommended divergent courses based on identical evidence, generating much confusion. Closer to home, selecting among treatments for presbyopia, astigmatism and even glaucoma and wet macular degeneration, are complicated by conflicting clinical opinions and competing treatment goals. Patients are bombarded with media messages about the virtues or pitfalls of specific approaches, often from sources with vested interests, which further complicates sound medical decision-making. Understanding the underlying “medical mindset” of your patients, yourself and experts may be the key to sorting it all out, oncologist Jerome Groopman MD and endocrinologist Pamela Hartzband MD told the American Society of Cataract and Refractive Surgery symposium. Research they conducted for their book, Your Medical Mind (The Penguin Press 2011), suggests that while specific medical decisions are highly individual, they are heavily influenced by a few identifiable factors.

Minimalist or maximalist?

Drs Groopman and Hartzband, who are at Harvard Medical School, began by asking how patients can make the best decisions in the face of controversy. “We didn’t have a ready answer so we began to search,” Dr Hartzband said. The classic model of medical decision-making, based on economic theory developed by the 18th century mathematician Daniel Bernoulli, proved problematic, said Dr Groopman, a medical writer for the New Yorker magazine. It attempts to quantify choices by multiplying the probability of a given outcome by the utility it will produce for the patient. This may work in business, where the outcome and utility are both measurable in money, Dr Groopman noted. In medicine, the chance of specific outcomes, such as side effects like incontinence or impotence after prostate surgery, may also be predictable. “But how do you put a number on the second part of the equation – the utility or impact that it has on your life?” One common way is to ask healthy people how much they think a given medical condition would affect their quality of life, from 0.0 being death to 1.0 perfect health. Blindness typically ranks 0.5. This methodology is used to quantify the value of outcomes in quality-adjusted life years for purposes of assessing the cost-effectiveness of medical treatments by agencies around the world, including the UK’s National Institute of Comparative Effectiveness. Problem is, these estimates by people who have not had a particular medical condition are very different from the self- reported quality of life of people who have the condition, Dr Groopman said. He has a cousin who is blind from birth, worked as a teacher, speaks four languages, is on the board of her synagogue and volunteers teaching visually impaired people how to use Braille keyboards.

“If you told my first cousin her life is worth 0.5 on a scale of 0 to 1, she would slug you.... This entire structure of medical decision-making is deeply flawed.” So, Dr Hartzband said, they turned to the advice of William Osler MD, a founder of modern medical practice, on making difficult diagnoses: Listen to the patient. If you know how to listen, he is telling you the answer. The two interviewed scores of patients of different ages from different backgrounds with different conditions on how they made medical decisions. Three major themes emerged, Dr Hartzband said, which are the following: – Some people are maximalists, who want "everything" done while others are minimalists who want the least treatment necessary; – Some people have a naturalism orientation, looking for natural solutions such as herbal medications and yoga while others have a technology orientation wanting the latest high-tech, cutting-edge treatment; – Finally, there are believers, who are certain that they will find a good solution for their condition, while others are doubters, who worry about side effects and poor outcomes. Regular PSA screening and aggressive surgical intervention for prostate cancer reflects a maximalist technologist believer mindset, while watchful waiting is more of a minimalist doubter approach, Dr Hartzband noted. Both approaches are supported by research, and patients following both report similar quality of life, Dr Groopman noted.

Three steps to better decisions

Matching the approach to the patient’s mindset may be the best way to begin medical decision-making, Drs Groopman and Hartzband said. Be aware that you and an expert panel may have a different orientation, and allow for that. Then look at the numbers, framing them in both a negative and positive way, and in both relative and absolute terms. For example, a one per cent to nine per cent complication rate also means a 91 per cent to 99 per cent success rate. A 30 per cent reduction in heart attack risk sounds great, but if the patient’s baseline risk is only two per cent, the absolute reduction is just 0.6 per cent. This helps cut through some of the confusion, they explained. Finally, both patients and physicians are deeply influenced by dramatic stories, what cognitive scientists call "availability". These stories may be misleading or helpful and should be balanced by the numbers, they concluded.