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After we spoke with Susan, we started to think about our own experiences with medical treatment, both as physicians and as patients. During many morning walks around our neighborhood, we had animated conversations about our own mind-sets, values, and preferences.

We realized that each of us had started our careers with a different conception of medical care. The old saw “Opposites attract” applied to us. One of us, like Michelle Byrd, believed in being as proactive as possible. The other, like Susan Powell, was deeply wary of overtreatment. We found this odd, since there was little difference between the medical schools where we’d trained and none between the hospitals where we’d worked.

We concluded that to better understand why patients choose as they do, we needed to first understand the origins of our own views about treatment and how they evolved.

Two

Believers and Doubters

One of the first skills that we learned as medical students was to “take a history” from a patient. We were taught to follow a structured sequence, first exploring when symptoms began, how they may have changed over time, what may have made them better or worse. Then we would ask the patient about his prior illnesses and therapies and the health of his family—grandparents, parents, and siblings. In the last part of the interview, we would ask about current and prior habits like cigarette smoking and alcohol consumption, as well as lifestyle, including exercise, diet, marital or other relationships, and the person’s type of work. All of this information gives doctors a clearer understanding of the nature and origin of the current condition and how it fits into the patient’s life as a whole.

We thought about unraveling preferences about treatment in much the same way we take a medical history. Family is the starting place for many people’s attitudes and values, and medicine is no exception. Around the kitchen table, during summer vacations, when holidays are celebrated, and the myriad other times families gather, people talk about health and illness, learning about the choices their relatives have made and forming a foundation for their own thinking. So we decided to consider the “family history” first. We then would explore previous experiences in navigating earlier medical problems, the “past medical history.” Next we would focus on knowledge about others who suffered similar maladies—friends, stories on television or in magazines, testimonials on the Internet—this was the “social history.” By focusing on these three elements, we hoped to create a framework that would help us to better understand preferences about treatment and how they came to be.

We decided to test this approach on ourselves to see what we would learn.

[Jerry’s Narrative]

“Cholesterol.”

I was eleven years old and had never heard the word before. It was 1963, and suddenly cholesterol seemed to be everywhere. Cholesterol was repeatedly invoked by my parents at the kitchen table. Reports filled TV broadcasts and the newspapers. Doctors were checking it, and the men in my neighborhood compared their results. My father’s level was high—exactly how high I don’t recall, but the number became an obsession in the family. Overnight, our cuisine changed. Egg yolks disappeared. Gone was the sweet butter. Hot pastrami sandwiches were restricted to special occasions and even then only extra-lean meat; the delicious edges of fat were removed.

A year after cholesterol was banished from our kitchen, the surgeon general of the United States released his report on the association of cigarette smoking with cancer. During the Second World War, my father joined the United States Army, was sent to France, and there became a smoker like so many of his fellow soldiers. My mother, a young beauty in the neighborhood when my father left for war, had grown into a mature woman. As a sign of independence and sophistication, she too started to smoke. Both my father and my mother quit cold turkey in response to the government report. Then my father’s blood pressure was found to be high.