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Minding patients’ preferences - EY - Global

Progressions 2012

Minding patients’ preferences

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A lot of medicine is gray, including diet and exercise.
  Jerome Groopman, MD
  Harvard Medical School and Beth Israel Deaconess Medical Center

  Pamela Hartzband, MD
  Harvard Medical School and Beth Israel Deaconess Medical Center

EY: Could you summarize some key findings from your recent book, Your Medical Mind?

Groopman: A central point is that relying on classical decision analysis paradigms to determine what's best for a patient doesn't work. The approach is popular among health policy planners in the UK, and it's being considered in the US. But the numerical value given to the expected utility of a treatment is basically meaningless. We argue that the approach fails largely because there are different categories of patient mind-set, with very different preferences.

Hartzband: We interviewed scores of US patients, with different backgrounds, states of health and socioeconomic circumstances, and found several categories of mind-set. Some patients are maximalists and want to do everything possible, while others are minimalists and believe less is more.

There are patients who want the most cutting-edge technology and those who prefer the most natural treatments — herbal medications, acupuncture, massage. Finally, there are believers and doubters. Believers are convinced there's a good treatment for them and they just have to find it, while doubters are always worried about side effects or unintended consequences. We profile patients of these types in our book.

These categories help explain a puzzle. As patients with the same treatment options become more informed, as you explain and make things clearer to them, you'd expect them to converge in their opinions about what treatment is best, but in fact they diverge. The explanation may be that underlying people's thinking are these different mind-sets.

EY: Your book highlights many gray areas where there's uncertainty and it's not clear what option is best. But aren't there also medical issues that are more black-and white — behaviors (e.g., poor diet, lack of exercise) that are clearly irrational?

Groopman: If you are hemorrhaging from a ruptured aortic aneurysm and you refuse to have it sewn up, or if you have overwhelming bacterial pneumonia and you refuse antibiotics, then yes, that's irrational. But a lot of medicine is gray, including diet and exercise. If you're starving or massively obese, you should certainly change your ways, but for the large middle range, the probability of adverse health impacts from weight gain is small, and recent data indicates there's little impact on mortality rates.

EY: Your book encourages patients to become informed and take control of their treatment decisions. Is this realistic in complex cases, and how can we help patients better prepare for these decisions?

Groopman: People greatly underestimate the intelligence or capacity of patients. One of my mentors in medical school said there's nothing in medicine that is so complicated it can't be explained to almost everyone. Is it realistic to expect patients to process all this information?

Not without help. One thing the book does is highlight a series of questions to help people figure out what information applies to them as individuals and what doesn't, the risks to them, how their personal characteristics may or may not correspond to guidelines.

Hartzband: If doctors spend the time, patients can understand enough to make just as good a decision as the doctors. It may not be the same decision, but that's not because patients are irrational or stupid. The difference is partly due to the fact that doctors, too, have the sorts of mind-sets we mentioned earlier, which may not match the patients'.

This article was featured in our report Progressions 2012 - the third place: health care everywhere.

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Progressions 2012: health care everywhere
Progressions 2012: health care everywhere
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