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Dave Simon, the avid tennis player with atrial fibrillation whom you met at the beginning of this book, was poised to make a serious treatment decision—caught between two images of the future, a stroke or severe hemorrhage. To complicate matters, a brand-new medication had just become available. This new blood thinner required less monitoring than warfarin, and studies showed a somewhat smaller risk of bleeding. But slightly more people had heart attacks while on this new drug, for unclear reasons. Dave’s cardiologist offered him the standard treatment options as well as this new medication. She showed Dave the number needed to treat with each drug, how many people needed to receive the medication to prevent one stroke from occurring. The doctor also informed Dave of what is termed “the number needed to harm,” meaning how many people typically must receive the drug for one person to have a serious side effect, in this case bleeding into the gastrointestinal tract or brain.

Dave went through a deliberate process, not only examining these numbers, but also considering his mind-set. Dave had a doubter approach to treatments. He was afraid to take any of these medications, but he realized he was more terrified of having a stroke. After several sleepless nights, he made his decision. “I decided to stick with the traditional blood thinner,” he told us. “I’m not an early adopter. I remembered what happened a few years ago with Vioxx, how excited everyone was about it and how doctors said it was so much better than aspirin and other drugs. Then they found out that it caused heart attacks, too. I prefer to take a medication with a longer track record.” Someone else with a believer orientation might eagerly greet the news of a new anticoagulant and request to be switched to it, even if he was doing well on his current therapy.

A team of researchers studying therapy of high blood pressure made a similar observation about the wide variety of patient preferences. In this study, researchers presented a series of scenarios about hypertension therapy to both physicians and patients. Physicians and patients then were asked to determine at what point the benefits of therapy outweighed the risk of side effects, cost, and inconvenience. The researchers found that given the same information, patients were generally less likely than doctors to accept treatment for high blood pressure. The patients tended to be more risk-averse, weighing the side effects of the medications more heavily than their doctors did.

In this study, one-third of the patients interviewed decided against drug therapy for high blood pressure when presented with a scenario that would qualify them for treatment based on expert opinion. Like Alex Miller, these patients didn’t want the therapy recommended by their doctors. But the researchers also found that a significant subgroup of patients (15 to 20 percent) wanted treatment that had no proven benefit and was not recommended. We would term these patients maximalists—like Michelle Byrd. These people often feel that they’re “ahead of the curve” in protecting their health, even though scientific data do not yet support their view.

Patients should be aware that there can be differing views among specialists about who should be treated for various conditions. For example, expert committees in Europe and the United States crafted different guidelines about when to treat high blood pressure. The group of American experts believed that the benefits outweighed the risks from treatment for mild elevation of blood pressure and wrote guidelines that advise medication for patients like Alex Miller. But in Europe, an expert committee with access to the same scientific data formulated different guidelines that don’t advise treatment for mild elevation of blood pressure. In Europe, Alex and others like him would not be encouraged to take medication. Different groups of experts can disagree significantly about what is “best practice.”

Dr. Rodney Hayward, a widely respected