Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [35]
Patients have often asked us the same question that Lisa posed to the orthopedic surgeon: “What would you do for your mother, your sister, or even for yourself?” This query is essentially asking, “Tell me what you really think is ‘best.’ ” The patient wants the physician to forget malpractice, cost, professional relationships, hospital affiliations, and anything else that might limit or influence his or her advice about treatment. But even with the same clinical problem, what is best for the surgeon’s mother might not be best for Lisa.
Our two mothers, in fact, had taken very different approaches to medical problems. One mother was a deep doubter and a minimalist; she had no place for authoritarian injunctions and recoiled when a doctor, with the best intentions, stated plainly what he thought she should do. The other, a maximalist and a believer in science and technology, profoundly respectful of the medical profession, would tell us, “The doctor said to do this, so I do it.” She never missed a pill, never resisted a procedure, certain that each recommendation was one step closer to regaining health. So the answer to Lisa’s question depends on several assumptions.
The first is that the mind-set and preferences of the doctor’s mother are the same as those of the patient who is asking the question. The second assumption is that there is a clear best option that every expert would agree upon.
Very often in medicine there is more than one way to address a problem. As we noted previously, much of medicine is still an uncertain science, existing in a gray zone—not clearly black or white. In Lisa’s case, some physicians might have advised her not to fuse the joint, leaving that as a later option should it be needed. Others would assert, as Lisa’s doctor did, that fusion clearly was required. Medical journals regularly feature articles that explore the differences in experts’ judgments about cases where there is no clear “best” approach. These kinds of complex and controversial cases are the regular focus of clinical conferences, where specialists discuss and debate the merits of different approaches.
We have no way to know what treatment was best for Lisa. In fact, from the outset there was uncertainty about the nature of her problem. “The surgeon gave me these vague responses when what I wanted was a clear weighing of how each of the problems in my foot, the bone spur, the ganglion cyst, the arthritis in the joint, contributed to my pain,” Lisa said. Of course, this kind of clarity is often impossible to achieve. Only after removing one or two or all three of these abnormalities could a more exact answer be given. That kind of uncertainty pervades much of medical decision making. And in situations where one can’t predict the outcome accurately, how the decision is made can be as important as what decision is made.
Lisa told us, “In this case, I wanted the ganglion cyst removed. And I wanted the bone spur removed. But I started getting really nervous about the fusion. If the foot doesn’t have a spur sticking into the joint anymore, if the ganglion cyst is removed, maybe the arthritis wouldn’t be that bad, maybe the joint would calm down.” This was her logic. “But I also wanted to believe that he was really on the right track and that he was going to fix my problem. I said to myself, Okay, you are going into surgery anyway, and I guess he knows best. So I listened to what he said. I usually advocate well for myself, but in this case, I did not.
“I should have erred on the conservative side,” she continued, “because the body has a powerful mechanism for healing itself.” Here, she was expressing her underlying naturalism orientation. Then she revealed a “minimalism” orientation as well. “My general philosophy about medicine is to do the least possible,” she told us.
It is often suggested to bring a friend or family member