The issue of choice has been an interesting topic this week. On Monday I posted a research study, which suggests that Choice Doesn’t Always Mean Well Being for Everyone. In response to that article, I received an e-mail recommending that I check out the presentation by psychologist Barry Schwartz on the Paradox of Choice, at the TED Conference.
Schwartz premise is that increasing choices ultimately results in making us confused and even reduces the chance that we’ll make a choice in the first place- it produces paralysis, rather than liberation. With more options to choose from, the more dissatisfied people are with their selection. It's easy to imagine that you could have made a different choice that would have been better. And what happens is this imagined alternative induces you to regret the decision you made, and this regret subtracts from the satisfaction you get out of the decision you made, even if it was a good decision. The more options there are, the easier it is to regret anything at all that is disappointing about the option that you chose.
Adding options to people's lives can't help but increase the expectations people have about how good those options will be. And what that's going to produce is less satisfaction with results, even when they're good results.
While I understood Schwartz’s frustration with an overwhelming set of choices in breakfast cereals, electronics and other material things I wasn’t so sure I agreed with his comments about health care.
It is no longer the case in the United States that you go to the doctor, and the doctor tells you what to do. Instead, you go to the doctor, and the doctor tells you, well, we could do A, or we could do B. A has these benefits, and these risks. B has these benefits, and these risks. What do you want to do? And you say, "Doc, what should I do?" And the doc says, A has these benefits and risks, and B has these benefits and risks. What do you want to do? And you say, "If you were me, Doc, what would you do?" And the doc says, "But I'm not you." And the result is -- we call it "patient autonomy," which makes it sound like a good thing. But what it really is is a shifting of the burden and the responsibility for decision-making from somebody who knows something -- namely the doctor -- to somebody who knows nothing and is almost certainly sick and thus not in the best shape to be making decisions -- namely the patient.
I disagree with Schwartz’s last statement. The doctor has one set of information about the patient, often in the form of test results and exams. Compare this to the patient and their family, who knows the patient's likes and dislikes as well as their beliefs and their ability to make changes etc. Ultimately, since it’s the patient that has to live with the decision rendered, why shouldn’t they be responsible for the choice?
However, this is just my viewpoint so I decided to do a survey of friends and colleagues, all of whom either are living with a chronic condition and/or are in the medical field. I asked about what level of choice they wanted in their healthcare, as well as how they went about making healthcare decisions for themselves. Needless to say, this is a biased sample and so findings can’t be generated much beyond the people that responded. Still the results were interesting.
Long story short, respondents wanted to make the choice about their health care. However, they wanted the assistance of a trusted medical provider and they didn’t want too many options, particularly ones that are conflicting.
I think making the decisions should still be a dialogue. Most important is for the patient to know consequences or possible outcomes. I have no problem with a physician making a strong case for a choice but ultimately I think a patient must decide if competent….. Two areas of physician in charge modality worry me: excessive testing and excessive end of life intervention….
I am most certainly in that very small group of “affluent educated westerners” who benefit from choice. I take my responsibility to monitor and be in charge of my own health care very seriously. There have been times when I have been really too sick to make any choices, and I try to choose doctors who will a) allow me to be a full partner in my health decisions and b) I would trust with my life if I am unable to hold up my end of that partnership.
I see my nurse practioner as a partner in health so to speak...she has suggestions; I consider them...if she has strong feelings about a particular issue, I listen more closely...However, I want to be in charge of my own health decisions. I believe as I age, this will be more important. Most doctors, at least, seem to see death as the enemy (at least in my experience), and are fairly quick to suggest stuff to ward off death regardless of whether that's a smart thing to do or not. …. I respect the knowledge and experience of my medical caregivers, and want their input, and want to know how strongly they feel about particular treatments, but I want to be the one to make the decisions. Perhaps once I’m older and possibly feeble minded, I will be more content to let them have more input and influence...
I probably wouldn't stay with a doctor who didn't involve me in the decision making process. But the patient has got to be informed.
To the question of how people go about making health care choices, there was a general consensus that getting information from a reliable source was very important. With the Internet, there are a host of options, some of which are just plain “snake oil.” There is also the possibility of “information overload.”
One person noted that the need for a quickly made choice is much different to one where you have time to think about the impact. The range of information provided indicates the complexities of making a choice. It is easy to see why, with more options being presented, the more complex the decision making becomes for the patient and ultimately why some patients just throw up their hands.
Several people recommended looking at complementary and alternative therapies as one of the choices and one respondent was very clear that cost and impact on her spouse were very important considerations. I suspect that cost is a much bigger factor than this survey would indicate. I also think that location of treatment and time away from work and family also plays in to decision making.
I ask a lot of questions and try to get as much information as I can. I consult with other patients and/or doctors, I read books and serious stuff on line (not chat room whining), all so that I understand the various factors at work.
I try to get as much information as possible, but in the end, many of my health choices boil down to gut instincts about what is right for me. I try to be very quiet and listen to my inner wisdom. Ultimately, I am looking to heal and this is not always an option with western medicine. So many doctors are satisfied to shoot for “remission” with drugs whose toxic side effects are “within acceptable limits”. I work very hard at reaching for the possibility of something much better than that….and to this end I turn over every leaf and follow every little trail I find. I listen to other patients and read as much as I can.
I don’t think there is one formula for health care decisions. So much depends on the circumstances.
I usually wait till the very last minute I can tolerate the pain to have bone and nerve stuff done. I usually feel I have to give my body the best chances possible, PT etc. to heal itself.
I make my health care decisions based mostly on cost and the impact my treatment is going to have on my husband. He works a second job just to make sure that I have health insurance and can pay for the medications I need every month. Even with insurance, my co-payments run as high as $500 per month! Because my husband works so many hours and is under the additional stress of worrying about my health, I tend to minimize the intrusions that my treatment is going to have on our (limited) time together so he doesn't have to bear any further burdens than he already does. For that reason, I have steered clear of some clinical trials and drug regimens that may cause me to have side effects that would cause him to worry even more than he already does.
I suppose I'd advise someone to look at a holistic approach to making any decisions and to be sure to include a place for alternative therapies that will bring them a sense of well-being and relaxation, and I think a psychotherapist is essential. Even if you don't think you need to talk to someone it can be extremely helpful, particularly if you need an advocate or assistance in sorting through various courses of treatment.
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