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How Do You Make Medical Decisions?

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Posted 6/12/2013 10:34 PM (GMT -5)
Shared Decision Making (SDM) is the way that physicians are now trained to practice medicine.  I have a strong hunch that the underbelly of many of the intense disagreements that occur at this forum are due to the various ways that each of us approaches medical decision-making. How we decide what to do about personal medical matters is important as more responsibility is shifted to patients and medical care becomes a shared enterprise.  

What are the major influencing factors in how you make medical decisions?  Do you prefer to let your doctor decide, since he or she has more expertise than you?  Do you research intensively, essentially making your own decisions based on the best information you can find about your medical condition?  Do you ask others with similar medical issues, weighing their opinion (lightly or heavily) to influence your decision.  Do you base your medical decisions on fear? Are you influenced by a previous medical failure?  A distrust of doctors? Are you strongly influenced by your spouse or partner?   Do you make decisions logically? Emotionally?  Do you make decisions quickly? Slowly? Do you second guess your decision?

These questions scratch the surface of how we make medical decisions.  There are many other questions that influence are decisions.

And of course, no decision is black or white, but a full spectrum of color.  I do, think, however that we have a strong magnetic pull towards certain ways of making medical decisions.

Regarding prostate cancer, I got a baseline PSA at age 40, nearly a quarter century ago.  Because my PSA quadrupled in a year, at age 55, my primary care provider sent me to a urologist for a consultation.  At that time (and to a certain extent today). PSA velocity was considered a primary indicator of the possibility of prostate cancer.  After a consultation with the urologist, we did a biopsy, which showed a single core of Gleeson 6 cancer.  Today, active surveillance would probably be suggested as the first and most favorable option.  My wife and I considered our options and my family history (My grandfather died of prostate cancer; my uncle had a prostatectomy; my brother died at 40 of another type of cancer). I based my decision on the medical recommendations at that time ( I read all the prostate cancer books I could get my hands on), my family history of cancer, my excellent health at the time--and the possibility that I could live another 40 years--and chose open prostatectomy (robotic was still new) over brachytherapy for a number of reasons important to me.  I live comfortably with that decision, but regret that the promised land of returned sexual function still eludes me.  

 

Posted 6/12/2013 10:45 PM (GMT -5)
Tim, you asked some great treatment questions, I will take a shot, strictly based on my own reaction and only in my own opinion, believe that is what you are looking for. Assuming you weren't asking rhetorical questions.
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Do you prefer to let your doctor decide, since he or she has more expertise than you? Yes, as a rule, especially if I really trust a particular doctor. They are the doctor, not me.

Do you research intensively, essentially making your own decisions based on the best information you can find about your medical condition? Moderately so, but not overkilling the research, depends on the subject

Do you ask others with similar medical issues, weighing their opinion (lightly or heavily) to influence your decision. Yes, but just for a reference point

Do you base your medical decisions on fear? Never

Are you influenced by a previous medical failure? Yes, especially with my track record

Are you strongly influenced by your spouse or partner? Not at all, my wife and I make our own medical decisions, then back each other's decisions

Do you make decisions logically? Absolutely, to the best of my ability

Emotionally? Never

Do you make decisions quickly? Generally, but was same way in business world

Slowly? Not typical for me, depends on severity of decision

Do you second guess your decision? Rarely

david
Posted 6/13/2013 12:33 AM (GMT -5)
Allen, Thanks for the reference to the earlier thread, which provided good reading. I'm interested in the neurobiology of decision-making, a subject addressed by Jason Zweig in his book on investing, and by David Brooks in his book on human social behavior.
Posted 6/13/2013 1:10 AM (GMT -5)
Thanks for those references -- I'll look into them. If you haven't read it, you might also enjoy "Thinking, Fast and Slow" by Daniel Kahneman. A lot of the learning from cognitive psych has been incorporated into buyer behavior/ purchase decision-making models used in Marketing and Economics these days -- the same models apply whether we're deciding which toaster to buy or deciding which prostate treatment is right for us (the parameters change a lot, of course). I think the recently announced government BRAIN project will provide a lot more info on this interesting area.

- Allen
Posted 6/13/2013 5:09 AM (GMT -5)
Interesting topic...
One thing I've noticed... My RadOnc often consults the hospital board about my case. Dr.s and nurses I haven't met, greet me at the hospital (photos are on my file). A bit odd feeling.
Here's my thinking...
The positive... Collective knowledge applied to my case. Can't be a bad thing, can it?
The negative... I have to convince a group of people to push the boundaries. I had this conversation with him last week. He said I was one of the ''key' patients they are following and they are discussing one step ahead all the time. Makes me wonder if protocol will get in the way of 'my plans'.

As for my plans... I research and bring question to talk about each visit. They often range in topics. The answers he gives me are not as important as the way he answers them. I want to know how he thinks. For example... Pom supplements... I don't care if he gives me the OK or not, I want to know if he thinks they are indifferent.
I don't know if this answers your questions, but I will follow this with interest.
Posted 6/13/2013 6:44 AM (GMT -5)
Great topic. I like to research enough that i can ask intelligent questions. I don't really distrust Doctors, but I don't put them on a pedestal either, each one needs to earn my respect. I have a need to be involved in the decisions and in some cases (like which treatment to get started with), I must have the final say. In the end, I guess if something goes wrong, I want to be able to say it was a risk I took and not blame anyone else. I do talk to others and get thier experiences, but mainly as a reference that has a "face" behind it as opposed to cold stats. My fiancee is the opposite, she listens to what people she knows tell her and doesn't question them. She's on my side though, in all of this, despite the fact I might not put as much weight on the opinions of her friends as she does. This is a deep topic and will require more thought on my part, but that's my quick answer.
Mike
Posted 6/13/2013 7:48 AM (GMT -5)
I approach medical decisions the same way that I approach all other decisions: cold, calculated, based on data and reliable statistics. I am an engineer and analyst, where data is king.

I look to doctors to help me find the relevant data and statistics, and not to advocate for me to make a particular decision.

This "let the data decide" approach becomes a bit more difficult when there is insufficient data to rely on when making a decision. For example, there is little data available on brachy treatment for guys in their 30s and early 40s. In this case, the absence of data itself is data, which is incorporated into the overall analysis when making a decision.

Yes, I'm a bit nutty. Have a nice day. :)

-Gedman
Posted 6/13/2013 7:58 AM (GMT -5)
I tend to research matters quite a bit.

Of course, most medical decisions are routine. I mean, even my surgeries (knee meniscus repair; inguinal hernia; basal cell carcinoma) were routine. I did a bit of research, but it was pretty much cut and dried.

With PC, I've been researching it for years!!! The more I learn, the more questions/uncertainties arise!

My relationship with my doctors is a sharing one. I usually come in with notes and we discuss stuff. It is a partnership.

Mel
Posted 6/13/2013 8:04 AM (GMT -5)
gedman, you're a man after my own heart.

I'm an engineer too, and the biggest frustration in this whole disease situation is the lack of data to guide treatment decisions. My urologist said few people with high risk, locally advanced cancer are interested in trials of different treatment options. The risks are just too high. We're on a precipice, and possibly like the coyote in the Roadrunner cartoons... we may have already run off the cliff but are still suspended in air because we don't know it yet. Advanced progression is in the near future without some intervention.

Someday there may be large, prospective, double-blind studies to guide these decisions, but the history of getting people enrolled in such appears to be pretty poor right now. They try, but just can't get enough cases on board to conduct the study. Heck, they still make statements like "There is no proof that treatment extends overall survival." I think the key word in there is *proof*.

So, how does an engineer make decisions without proven data? It's all pretty mushy....
Posted 6/13/2013 8:29 AM (GMT -5)
In case anyone is interested (and this may answer Redwing57's question, a bit), here is a handy/powerful mechanism for making decisions where there are multiple options and each option has multiple criteria.

For example, someone with PCa may need to choose between Brachy, Surgery, AS and Hormone treatments. For each option, there are pros and cons spanning numerous criteria, such as survival rate, cost, ED impact, continence impact, aversion to overnight hospital stays, aversion to anesthesia, access to an excellent doctor in that specialty, and any other criteria that a person may want to include in their decision process.

You can "crunch the data" by using something called a Decision Matrix.
Wikipedia explains it like this: en.wikipedia.org/wiki/Decision_matrix
But I think that this this simple example is easier to understand: /depts.washington.edu/oei/resources/toolsTemplates/Decision_Selection_Matrix.pdf
Here is a more detailed explanation: rfptemplates.technologyevaluation.com/what-is-a-decision-matrix.html

-Gedman
Posted 6/13/2013 9:32 AM (GMT -5)
Allen--I will read Kahneman's book. Interestingly, here is a link to an editorial that David Brooks wrote in 2011 about Kahneman.
Posted 6/13/2013 11:36 AM (GMT -5)
I am an engineer and a troubleshooter. I approach it like I would any troubleshooting problem - collect evidence, review possible solutions, weigh the risk/rewards of solutions, consider the cost of doing nothing and then make a choice. My doctor is an expert opinion, source of quality test information and often the contractor I hire to implement the fix.

The decision is mine - unless my wife speaks up tells me to do something...
Posted 6/13/2013 12:33 PM (GMT -5)
I, like In the Shop, see medical issues as a problem to be solved and approach it like any other complex problem. First I have to understand how it works. In regards to PC this means how does it grow, what are it's manifestations, what different types of disease are there and how do you tell the difference (i.e. aggressive vs non aggressive; contained vs systemic). Once you have these answers you can fit the treatment to the type of cancer you have. Then find the absolute best doctor that does the type of treatment you have decided on.
I ask my doctors a lot of questions about "why" he thinks his recommendations are correct. Then I verify his recommendations by researching articles and asking more questions about what I have discovered by reading. I also ask given my situation who would be the best doctor to perform the treatment, who would be the best doctor to monitor my situation.
Posted 6/13/2013 2:22 PM (GMT -5)
I used to have the following tagline, which somehow seems to fit this topic:
Remember, if you can keep your head when everone else around you is losing theirs and panicking....

Then perhaps you don't fully understand the situation!

Mel
Posted 6/14/2013 2:00 AM (GMT -5)
Depending on what the medical condition is, all of the above.   The doctor's opinion and a second opinion is probably the best answer!  (Yes, we do pray about it.)
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