Making health decisions: mindsets, numbers, and stories

How do people make decisions about their health and medical treatment? It’s something I think about, and try to help with, as editor of the Harvard Heart Letter. So it was interesting to take a busman’s holiday to listen to two thoughtful physicians who have grappled with that very question.

Drs. Jerome Groopman and Pamela Hartzband, both faculty members at Harvard Medical School and physicians at Beth Israel Deaconess Medical Center, have written a new book called Your Medical Mind. Its main topic is how people make medical decisions. They spoke about their work in the inaugural Health Information Lunchtime Lecture Series in Consumer Health at Harvard Medical School’s Countway Library of Medicine.

The husband-and-wife team pointed to three basic influences that drive our medical decisions: our mindset or general approach to medical matters, numbers (medical data and how they are presented), and stories. Stories, say the authors, are often the most compelling force in making medical decisions. “Scientists in general hate stories,” joked Dr. Groopman. “But most of us understand our world through narratives.”

Groopman and Hartzband distilled interviews with scores of patients to arrive at general mindsets that shape medical decisions. Some people are maximalists, who are willing to undergo whatever test or treatment might help. Their opposites, the minimalists, prefer as little intervention as possible. Naturalists opt for an herbal preparation that is chemically identical to a drug produced in a lab, while technologists would prefer the synthetic formulation. (The speakers surmised that the recently deceased Steve Jobs was a curious combination: a naturalist-maximalist.)

There are also the believers, who take what their doctors say as gospel, and doubters, who search for any possible evidence that their doctors’ recommendations might be worse than the diseases they treat.

These mindsets, Drs. Groopman and Hartzband emphasized, can and do change in the face of new numbers, well-framed advice from physicians, compelling stories from friends and family, and, alas, stories of another kind: direct-to-consumer advertising. “If you regularly watch the evening news and a couple of hours of prime time TV, you’ll see about 16 hours of drug ads a year,” Dr. Hartzband noted. “That’s a lot more time than you probably spend with your doctor.”

In an ideal world, medical decisions would be based partly on incontrovertible and unambiguous numbers, but “evidence, data, numbers, and studies are imperfect and often flawed,” Dr. Groopman said. “There are no black and white answers.” Even the so-called expert panels, which have recently disagreed about high-stakes matters such as screening for breast and prostate cancer, layer subjective interpretations onto the hard numbers.

Both authors conceded that, during medical training, they weren’t taught how patient preferences are formed or how to elicit them. Today Dr. Hartzband does it this way: “After explaining the options as neutrally as possible, I ask, ‘Tell me what you’re thinking?’ I listen and make a special effort not to present my point of view until I’ve heard from my patient.”

This is a good reminder to let our doctors know what we’re thinking, whether we’re specifically asked or not.