Thursday, October 6, 2011

Your Medical Mind by Groopman and Hartzband - Book Review

 Your Medical Mind: How to Decide What is Right for You by Jerome Groopman, MD and Pamela Hartzband, MD (Mrs Jerome Groopman) is not your mother's self-help book, despite its unfortunate sub-title. Rather, it serves as both a guide to examining yourself, your illness, and the approach your doctor chooses to take in your treatment as well as developing ideas about medical decision-making having important policy implications for legislators, regulators, and health care administrators. While not a sequel, it also functions as an excellent companion piece to Groopman's earlier work, How Doctors Think which I reviewed in 2008. In the earlier book, Groopman examined the various factors, both internal and external affecting how doctors arrive at decisions, with particular emphasis on their willingness to jump too quickly to what they consider a conclusive diagnosis. He also examines the effects of technology, drug companies, and insurance companies in making many doctors less effective through economic pressures. In Your Medical Mind, Groopman and Hartzband expand on his earlier book by bringing to bear additional psychological, sociological, and scientific thinking to assist patients in understanding their own approach to their illnesses as well as relationships to their doctors and families. The result is thought provoking, highly readable, and important.

Pamela Hartzband & Jerome Groopman

Jerome Groopman, MD holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and is the Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston. He specializes in oncology and hematology. Much of his research has centered on cancer and AIDS. He is also a staff writer on medical matters at The New Yorker and has published many juried scientific articles as well. (Wikipedia). Groopman has published four previous books. Pamela Hartzband, MD is a Board Certified specialist in Internal Medicine who also teaches at Harvard and practices at Beth Israel Deaconess Medical Center in Boston. She specializes in endocrinology and diabetes, Hartzband has published widely in the medical literature, often collaborating with Groopman, to whom she is married. This is their first book together.

The authors describe three basic postures patients can take towards the application of medical care. Some patients prefer to take a “naturalist” position, allowing the body to heal itself within a context of proper diet and plenty of exercise. Others, on the opposite end of a spectrum take an “activist” posture, choosing to use new medicines and cutting edge technology to attack their illness medically and surgically. Still a third posture towards decision-making in medical choices is that of the doubters, who question the variety of choices available, having difficulty making choices for themselves and seeking multiple sources of medical advice. Knowing their own predilection helps patients to understand how and why they respond the way they do and to integrate the advice of their doctors into their own schemes for achieving a cure or making medical progress.

Groopman and Hartzband stud their analyses with case histories of people suffering from various diseases, describing through in-depth interviews plumbing the depths of the patient's responses to their doctors and their own illnesses, as well as the effect of the illness on their preferred life-style. They describe the way patients use stories, their own and those they hear, to create their own medical imaginations. These stories help shape the way decisions are made. Stories may be suspect because they represent insufficient numbers (data) for good decisions, but when people hear a story that resonates within, they can latch onto them as anchors for opinions and decisions. This leads to an important conflict between anecdotal reasoning and evidence based choices.

Reasoning based on statistics represents an important element in making medical choices. What are patients' odds given the severity of their disease and the efficacy of particular treatments? On the other hand, the authors argue the current trend towards making decisions based solely on numbers is not in the best interests of any particular patient. They recall the current insurance company add in which a person (maybe a grizzled old biker or a young vibrant teenage surfer) goes about life with a series of numbers superimposed on their bodies. The commentator oozes sincerity, saying the numbers show the best route towards the “correct” treatments to save lives. This is all well and good, and statistical medical analysis can point the direction towards proper treatment, but cannot be the only indicator used because the “best practice” is a statistical average, not necessarily a decider of the best approach for any individual since individual belief systems and postures toward medicine must be taken into account in making the correct choices for each one. Such decisions are made by patients guided by caring, empathic informed physicians and their own personal beliefs and preferences. The insurance driven model provides insufficient time for helping patients make the correct choices. Groopman and Hartzband use diseases with competing responses and possible multiple outcomes to help illustrate these difficulties. By telling stories about patients with prostate and breast cancer as well as an auto immune disease, they illustrate how personal postures towards medicine and choices about life-style help govern making medical choices that can be correct for each individual, but such an approach is time consuming, and taking time costs money. “We agree strongly with Hayward [a medical researcher] that within the substantial gray area of indeterminate net benefit, “physicians should defer to an individual patient's preferences in choosing whether or not to intervene.” (pg. 63) Discovering patients' preferences is difficult, particularly with doctors' tendency to take quick action is considered.

The authors hold that all medical decisions are, to some extent, subjective for both patients and doctors. They say patients should always be informed about the “gray zones in medicine.” (65) They also stand in the face of the current trend towards basing choices almost completely on the numbers. Groopman and Hartzband rely heavily on choice theory drawn from economics and cognitive psychology. They ask how patients make choices on the basis of the information available to them and their knowledge (or lack of knowledge) about themselves. One of the great strengths of this book lies in helping us medical consumers gain a better understanding of what our own posture toward intervention is and how we arrived at it. As both a former teacher and a medical consumer, I find such arguments strongly persuasive. As a person who, at least by training, is inclined toward the idea of “best practices,” in the classroom and the examination room, I am impressed by the strength of the authors' arguments that informed patient preferences should govern them. Such choices only become more difficult in end-of-life situations where gravely ill patients' postures may change from previously expressed, or even written and attested to directives, beliefs about the correct choices for them. Here's where patient, doctor, and the patient's family need to meet, discuss, and choose the correct path for each individual. Such meetings are hardly death panels.

The authors consider the use of anecdotal evidence gathered from friends and acquaintances, the necessity for gaining autonomy and developing coping mechanisms, and the conflict between ideals and reality in the decision-making process. They are particularly strong in their chapter about end-of-life decisions and the responsibility of doctor and family when patients can no longer make their own choices. They emphasize the extent to which decisions have become increasingly difficult and more informed as everyone has gained access to the range of choices available through the Internet. They are deeply empathetic in their approach to the dilemmas faced by patients as they consider the range of alternatives available. This is a deeply human book leading its readers toward increased insight based on data and self-understanding. It stands as a model for books designed to help each individual approach the self through insight and the desire to gain understanding. It is miles away from the breezy certainty of many self-help books, which provide answers. Groopman and Hartzband ask the right questions, suggest some approaches that work for different people based on their own postures toward their health, and point the way to a collaborative, respectful, humane way to make the most difficult decisions there are, those dealing with life and death. This volumes is highly recommended.

Your Medical Mind: How To Decide What Is Right for You by Jerome Groopman, MD and Pamela Hartzband, MD is a 2011 publication from The Penguin Press. It was provided to me from the publisher through TLC Book Tours.