Say you’re a woman in your 40s, trying to decide whether to have a mammogram every year or every other year. You have the test, and an early cancer is detected. Should you choose a lumpectomy or a mastectomy? Chemo? Radiation? Anti-hormonal medication? How about being tested for the BRCA gene that predisposes women to breast and ovarian malignancies? If that’s positive will you have both of your breasts and your ovaries removed? And which doctors at what hospital will help you make these tough decisions?
Once upon a time things were simpler. Doctors didn’t have as many testing or treatment options to offer, and patients weren’t expected to play an active role in choosing among them. Doc said “penicillin’’ or “hysterectomy’’ and you complied - even if you didn’t understand all the potential risks and benefits; even, in many cases, if you didn’t really understand what was the matter with you. Today, medical decision-making - both clinicians’ and patients’ - has become so complex that some physicians spend their careers researching it.
Several recent books, including Atul Gawande’s “The Checklist Manifesto’’ and Jerome Groopman’s “How Doctors Think,’’ have examined how a doctor decides on a course of action in diagnosis and treatment. There hasn’t, however, been as much written about how patients approach their own medical choices.
“Your Medical Mind: How to Decide What Is Right for You,’’ written by Groopman, Harvard HIV and cancer specialist and a staff writer for The New Yorker, and his wife, Harvard endocrinologist Pamela Hartzband, fills that void admirably.
Like Groopman’s other popular books, “Your Medical Mind’’ features engaging stories of patients facing dilemmas. Here those dilemmas are decisions: whether to take a medication, to have more or less aggressive treatment for prostate cancer, to undergo a liver transplant. Each chapter looks at different aspects of the process: how to weigh statistics, advice from various sources, and your own fear, insecurity, and indecisiveness.
Though the book’s subtitle implies that this is a “how to’’ book, it is actually more descriptive than prescriptive. In fact, it might have been called “How Patients Think.’’ Groopman and Hartzband’s main point is that people make better choices when they understand some of the thoughts and biases that they bring with them to a doctor’s office.
They recommend a simple but fascinating exercise to uncover these thoughts and biases: Write a history of your relationship with illness and doctors. In the most personal section of the book - one that fans of Groopman’s essays about his own experiences as a physician will enjoy particularly - Groopman and Hartzband offer accounts of how early experiences influenced their own medical decision-making.
The death of his father at 55 from heart disease in a less-than-up-to-date hospital affected Groopman’s decision to take cholesterol-lowering medication decades later. In contrast, Hartzband’s parents’ enthusiasm for vigorous exercise and natural foods made her less likely, as an adult, to take medications or have high-tech diagnostic tests.
Groopman concludes he is a “maximalist’’ regarding his medical care while Hartzband labels herself a “minimalist.’’ These are two of several mindsets they identify, taking into account patients’ levels of skepticism, faith in technology, and inclination to receive more or less treatment and testing. The authors use many patient anecdotes to illustrate these mindsets. Extensive referencing of research - both into the hazards and efficacy of treatments and into the decision-making process itself - further strengthens and enlivens their argument.
Interestingly, Groopman and Hartzband mention that writing the book has affected their medical practices. “It changed how we, as physicians, help our patients make decisions about treatment,’’ they write. They have found that giving patients a new “vocabulary’’ to understand how they approach decisions can be therapeutic.
“Your Medical Mind’’ is a welcome and overdue comprehensive exploration of the patient’s perspective as he or she navigates the dizzying array of choices modern medicine presents.Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital and writes the monthly “In Practice’’ column for the Globe. She can be reached at email@example.com