Medical decision-making among treatment options: The signature medical mistake of my life

     Dr. Jerome Groopman and Dr. Pamela Hartzband wrote a clear and insightful book, Your Medical Mind:  How to decide what is right for you.  They illustrate decision-making through stories about themselves and their patients.

     Dr. Groopman’s father died from poor care for a heart attack, back in the days when some doctors thought that removing the heart attack patient’s blood would unburden the failing heart.  As a reaction, Dr. Groopman became a “maximalist,” believing that modern medical interventions were generally good things.  Following that belief, when suffering from persistent excruciating back pain, he opted for aggressive surgery—spinal fusion--when merely waiting might have been preferable.  The surgery gave him lasting pain and debility; he called it “the signature medical mistake of my life,” with disastrous consequences.  It also gave him a long-term belief in making more nuanced decisions about treatments for himself and his patients. 

     Years later, his doctor advised him to take a statin to reduce his high cholesterol.  In light of the heart disease in his family, he knew he had to do something.  However, Dr. Groopman knew of a friend who had incurred lasting muscle pain, a common side effect of statins.  So he negotiated with his doctor to take a smaller dose of statins, and found that the smaller dose was great enough to lower his cholesterol, and yet small enough to avoid any muscle pain.  

Advice to patients:  Learn from the experiences you and your friends have had and your family history.  Consider them and your biases when making decisions about your medical treatment.  

Read another story about deciding among one’s options for medical treatment.

Santa’s doctor writes: My letter to the North Pole

Dear Santa,

Your lab tests came back, and your cholesterol ratios are out of line, again. As I mentioned in your physical, I’m concerned about some of your habits. For almost the entire year, you’re very inactive. Living as you do in a very isolated neighborhood in a very cold region, you don’t get out and about very much. That isolation can be very dangerous for a man of your age (or, indeed, of any age). Then in late December, you rouse yourself for a short period of supremely intense activity, logging many miles over rough terrain, and then wrestling heavy awkward bundles out of the sleigh, then climbing up icy roofs while lugging these countless loads, then forcing yourself down through narrow spaces, then hauling yourself back up, and on to the next place. For a man of your girth and your age, it’s simply too much.

I’ve explained all this at your last physical, as I do every year. I’m writing this letter out of frustration, since you never do what I say. I never hear that you’re taking the niacin I’ve suggested, or the statin I’ve prescribed, for your high cholesterol. I never see any evidence that you’ve lost weight.

To be fair, I do want to applaud you for the healthy habits you do follow. You’re exceedingly generous, and selfless, as you love giving things to people. Your belly laugh is a real gift to others, and to yourself, as it discharges a lot of the tension that might otherwise lead to high blood pressure. The affectionate attention you give to the young children brought to you by their parents is good for them, and for you. You have a definite mission in life, and you serve it diligently, which also helps. You haven’t seem to age much over the years, so it must be that these healthy habits have been giving you these long years of healthy life in your old age, counteracting the factors I mentioned earlier.

I’ve long wondered about your ruddy cheeks and nose. In many people, that’s a sign of heavy drinking: after many years of drinking, the capillaries in a person’s face rupture. But when I’ve asked, you’ve consistently denied that alcohol has been a problem for you, and I’m inclined to agree, as I’ve never heard, from you or anyone else, that your behavior has been inappropriate due to alcohol. Indeed, moderate drinking (one or two a day, for a large adult male) is a healthy behavior, so it seems that you’re OK there.

So, what is my wish for you for Christmas? Get out and about the other 11 months of the year; spread the cheer year-round. Get some more helpers, and don’t limit your deliveries of all that stuff to such a short period of time. And take the cholesterol meds!

Yes, I’ve said that before (every year, indeed) at your physical. So let’s also try something different, since that hasn’t had any effect: a shared medical appointment. I’d like to form a group you’ll feel comfortable with. I’m thinking of other altruistic people who do too much, neglecting their own health. There are lots of very driven, loving, compassionate doctors and nurses out there, for example, who are overweight and aren’t following the medical advice they know so well. I’d like to get you all together, and we’ll have some fun swapping stories. I’d like to get the group sharing some of the ways they stay healthy. They, and you, might learn from peers, and might find those ideas more compelling than following a doctor’s advice per se. That’s my wish for you.

For my own gift this Christmas, thanks, but I already have plenty of golf clubs. Give a gift for me to Heifer International, which gets farm animals to poor people around the world. Just mail them a check; don’t lug around any of their water buffaloes!

My best wishes for another year of health,

Your doctor.

Ken's Advice: As a stocking-stuffer for a parent, get Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

More days happy than in the blues: A coach for diabetes care

Maria is a 66-eary-old Hispanic woman with diabetes. She receives her primary care at Massachusetts General Hospital's Chelsea health center. At her last visit in June of 2006, Maris had far too much glucose [sugar] in her blood; her hemoglobin HbA1c was 12.6, far more than a normal level of about 7. Her doctor referred her to a diabetes "coach," a multilingual, bicultural layman trained to identify barriers to care management and to assist patients in addressing barriers.

After several counseling sessions, the coach learned that Maria was taking one of her medications "only when I feel my blood sugar is too high," and was not taking her other medication at all because "it makes me dizzy." Maria was overweight, and ate a lot of rice, bread, pasta and other carbohydrates, and foods high in cholesterol like pizza, pork, meat, and fried food. She would not eat at all when she felt that her blood sugar was elevated. She was not exercising and reported often feeling depressed and "in the blues."

After working with the coach, Maria began taking both of her medications regularly and eating better. She cut down on carbohydrates and started eating more vegetables and fruit. She also ate more frequently in small portions. Due to her arthritis, exercise was a challenge for Maria, but she managed to walk 20 minutes on most days. In just a few months she lost 30 pounds. After 11 sessions with the coach, Maria felt very pleased with her progress, she is more confident, and has "more days happy than in the blues." When last seen by her coach in December, Maria's hemoglobin HbA1c had fallen to 7.7.

Advice for people with diabetes or another chronic health issue: ask your insurer to assign you a health coach.

Read an athlete’s diabetes story.

Thanks for our source, the 2006 Annual Report on Mass General's Community Benefit Program.

You are my best patient: Partnering with your doctor

From Steve Schalchlin's online diary, Living in the Bonus Round:

[W]hen we got home, there was a message from the doctor's office with my blood test results. Dr. Ruchi came on the line and literally said, "Are you sitting down?"
I sat down. She said, "Your triglyceride level is..."

I held my breath.

"...171."

I screamed, "ARE YOU SERIOUS???"

She said, "You are my best patient. It's amazing."

171. I was hoping for less than 400. She continued, "And this has brought your cholesterol level down to 120."

I'm glad I was sitting down. Passing up all that KFC was working. It's driving Jimmy crazy that the only thing he can cook for me anymore is chicken.

Now, the last time I got my levels this low, I celebrated by ordering a huge pizza. Then I got lazy. But not this time.

I realize that I can't afford to ever stop training.

Advice to patients: Never stop training! Do the hard work, if that's what it takes, to be their best patient. And if you see any chicken-free recipes that will help Steve keep his cholesterol down, send 'em in, to keep Jimmy sane... ;-)