She said it better.
There comes a time in every writer’s life when she realizes someone else said it better. A fellow blogger, John Mandrola, pointed out a piece in the New England Journal of Medicine that I am happy to say is better than anything I could have written. Called “Invisible Risks, Emotional Choices – Mammography and Medical Decision Making”, written by Dr. Lisa Rosenbaum, it can be found at http://www.nejm.org/doi/full/10.1056/NEJMms1409003. Dr. Rosenbaum talks about the ways in which patients make decisions, and how at odds those decisions can be with the scientific evidence. Here is what what she says:
“We do not think risk; we feel it. As research on risk perception has shown, we are often guided by intuition and affect. For example, when our general impressions of a technology are positive, we tend to assume that its benefits are high and its risks are low. We estimate our personal risks of disease not on the basis of algorithms and risk calculators, but rather according to how similar we are, in ways we can observe, to people we know who have the disease. And when we fear something, we are far more sensitive to the mere possibility of its occurrence than its actual probability.”
Decision-making pitfalls are extremely common sources of poor choices. We have to be able to predict how we will feel at a later date, for one thing. As Dan Ariely says in his book Predictably Irrational, “To make informed decisions we need to somehow experience and understand the emotional state we will be in at the other side of the experience.” We also have to understand the availability heuristic. Here’s Barry Schwatrz in The Paradox of Choice, talking about a study in which people looked at newspapers and then were asked to estimate the risk of death for various scenarios.: “People mistook the pervasiveness of newspaper stories about homicides, accidents, or fires – vivid, salient, and easily available to memory – as a sign of the frequency of the events these stories profiled. This distortion causes us to miscalculate dramatically the various risks we face in life.” We must also be aware of the influence of our emotions, our assumptions, who we talked to last week, prior experience, and a host of other very personal factors.
In the case of medical decision-making, fear is a powerful motivator. Fear can turn all of us into irrational beings especially if, as Schwartz points out, it causes us to miscalculate the actual risk of something we fear coming to pass. The current Ebola outbreak is a perfect example of this. Every new Ebola case is covered extensively in the news, governors get on TV reassuring large populations, thousands of people can’t get into the US without someone sticking a thermometer in their mouths, and two- to three-week quarantines are instituted for everyone who knows every victim. The fact that the incidence of Ebola in the US is currently on the order of 4/330,000,000 and that in order to get the disease you have to have had physical and intimate contact with the bodily fluids of an infected person has no bearing at all on people’s fear.
It is important for doctors to understand these pitfalls to good choice, because it affects many areas of our practice, including vaccinations, mammography, cancer screenings of all kinds, cardiovascular risk management, and even flu shots. Read Dr. Rosenbaum’s article. She says it better than me.