decision making


Stent Vs. Meds: Do You Even Know Your Options?


A bit more from today’s Boston Globe’s health bounty: Chelsea Conaboy smartly juxtaposes two recent studies about heart disease care here.

In a nutshell: A review of previous studies found that “implanting stents, tubes used to prop open a blocked artery, in patients with stable coronary artery disease was no more effective than using medications.” (That review was in the Archives of Internal Medicine of Feb. 27, and here’s the New York Times report.)

A day later, a study in the Journal of General Medicine found, as Chelsea sums it up, “Few Medicare patients who had a coronary artery stent implanted said doctors spent time discussing alternatives.” The press release for the study was even a bit more dramatic, describing the findings like this:

Nine out of 10 Medicare patients who received a stent procedure for coronary artery disease report their physicians didn’t present them with an alternative of managing their condition with medication, according to results of a survey published online today by the Journal of General Internal Medicine.

The study concludes that patients are not always fully informed of their treatment options, and physicians should increase efforts to involve patients in decisions before performing elective procedures. For example, stenting can provide relief from chest pain, but comparable benefits for most patients can be achieved with good medical management and lifestyle changes, as noted in another study published last week.

My takeaway: If your doctor doesn’t mention alternatives to stents, you might want to ask…

‘Your Medical Mind’: Know Thyself, And The Numbers

Drs. Jerome Groopman and Pamela Hartzband are a Longwood-style literary power couple: both on the staffs of Beth Israel Deaconess Medical Center and Harvard Medical School, and widely read in prominent publications from The New Yorker to The New England Journal of Medicine. We spoke this morning about the lessons that can be learned from the vivid stories and psychological insights in their new book.

I derived two takeaways from “Your Medical Mind.” First, you need to be aware of your own biases on medical decisions: Are you a minimalist when it comes to treatment, or a maximalist? Do you tend toward the natural or the technological?

Second, you need to understand decision dynamics that are common to all of us: Our tendency to be influenced disproportionately by what happens to people we know, for example. Our greater willingness to take a risk by not taking action than by doing something.

The federal Agency for Healthcare Research and Quality has just come out with a succinct cheat sheet, a list of questions to ask your doctor, from ‘What is the test for?’ to ‘Are there any side effects?’ I wonder if you could generate on the fly a list of the questions you should ask yourself before you finalize any medical decision?

1. What is my medical mindset?

JG: The questions you refer to from the government are generic questions, and they’re valuable. But the questions you should ask yourself first are: What is my medical mind? Am I a maximalist, so I believe in being proactive, ahead of the curve, doing everything and more? Or am I a minimalist, so I believe that less is more?

Drs. Hartzband and Groopman

PH: And to expand upon that: Are you somebody who likes the latest technology, do you have a technological orientation? Or are you somebody who is more in tune with natural remedies and prefers to go that route?

And finally, are you a believer or a doubter? The believers are people who believe there’s a solution to their problem and they’re going to find it and go with it. And the doubters are people who worry about side effects and unintended consequences, the people who are risk-averse and worry the treatment will be worse than the disease. So that’s your first question: What is your medical mindset?

2. What are the numbers? Continue reading