Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [24]
Patrick views the need to take thyroid medication permanently in strongly negative terms. So for him, radioactive iodine and surgery have much less “utility” than antithyroid medication and would not be valued as “best” for him.
Of course, another patient might solve this equation differently.
Anna Gonzales, a forty-two-year-old journalist with three teenage children and a hectic schedule, also developed Graves’ disease. When her endocrinologist suggested treatment with radioactive iodine, she readily agreed. “I want this taken care of quickly,” she explained. When we asked her if she was bothered by the idea of taking a pill every day, she replied, “Well, I already take a birth control pill. This is not a problem for me.”
Lily Chan, a twenty-seven-year-old social worker, chose surgery for treatment of her Graves’ disease. “I’m really afraid of radioactive iodine,” she told us. “No one can guarantee 100 percent that I won’t have some kind of side effect that is not known about now, maybe even cancer.”
But Patrick had no fear of radiation and no particular bias against surgery. “I simply don’t want to be forced to take another pill every day for the rest of my life,” he told us.
In the field of decision analysis, the utility or value that a person assigns to a particular outcome is termed his “preference.” Researchers have found that patients often construct their preferences on the spot when the doctor gives a diagnosis and recommends a treatment. Such patients are something of a “blank slate” upon which the doctor can “write” his or her own preference. In this setting, the patient is especially susceptible to how the physician frames the pros and cons of the treatment.
The endocrinologist who advised Patrick framed his remarks in a way that clearly reflected his own bias by emphasizing the side effects of treatments other than radioactive iodine. He presented radioactive iodine as the standard or “default” option. Research in behavioral psychology shows that most people will accept the default option; they assume that what is routinely recommended is “best.” It takes effort for a non-expert to decline the default option and seek an alternative. But that’s exactly what Patrick did. Because of his prior experiences with diabetes, he’d developed certain views about health. He wasn’t a “blank slate,” and he didn’t construct his preferences on the spot. For him, past was prologue.
We should then ask why Patrick’s endocrinologist had such a strong bias for radioactive iodine and framed his advice as he did. Perhaps he’d had bad experiences with antithyroid medications, where a patient had suffered a sharp drop in white blood cell count and developed a serious infection; or perhaps one of his patients had suffered serious complications from thyroid surgery. If so, this would reflect an “availability” bias: a dramatic past case readily recalled that colored the doctor’s thinking. But it simply may be that the endocrinologist was conforming to the cultural preference of his colleagues in the United States and that if he had been practicing in Europe or Japan, he would have conformed to the prevailing biases in those regions.
Patrick Baptiste had accepted and adapted to one chronic condition, diabetes. He felt that adding a second chronic condition, permanent hypothyroidism that required daily treatment, would deeply disturb his life. Such strongly held personal views are at times difficult for others to fathom. The endocrinologist who evaluated Patrick could not understand why adding one more pill could be a “big deal.” Indeed, as physicians, we often prescribe medication with the assumption that it is “no big deal.” And we assume that the patient will feel the same. However, a study of common medical conditions—including osteoarthritis of the hip and knee, benign enlargement of the prostate gland, or a ruptured disk—found significant differences in how patients and physicians weighed the goals and consequences