An economics professor writes:
Why We Make Bad Decisions
By NOREENA HERTZ
LONDON — SIX years ago I was struck down with a mystery illness. My weight dropped by 30 pounds in three months. I experienced searing stomach pain, felt utterly exhausted and no matter how much I ate, I couldn’t gain an ounce.
... It was terrifying. ... Trying to find the answer, I saw doctors in London, New York, Minnesota and Chicago. ... I was offered a vast range of potential diagnoses. ... Treatments suggested ranged from a five-hour, high-risk surgery to remove a portion of my stomach, to lumbar spine injections to numb nerve paths, to a prescription of antidepressants.
Faced with all these confusing and conflicting opinions, I had to work out which expert to trust, whom to believe and whose advice to follow. As an economist specializing in the global economy, international trade and debt, I have spent most of my career helping others make big decisions — prime ministers, presidents and chief executives — and so I’m all too aware of the risks and dangers of poor choices in the public as well as the private sphere. But up until then I hadn’t thought much about the process of decision making. So in between M.R.I.’s, CT scans and spinal taps, I dove into the academic literature on decision making. Not just in my field but also in neuroscience, psychology, sociology, information science, political science and history.
What did I learn?
Physicians do get things wrong, remarkably often. Studies have shown that up to one in five patients are misdiagnosed. In the United States and Canada it is estimated that 50,000 hospital deaths each year could have been prevented if the real cause of illness had been correctly identified.
Yet people are loath to challenge experts. In a 2009 experiment carried out at Emory University, a group of adults was asked to make a decision while contemplating an expert’s claims, in this case, a financial expert. A functional M.R.I. scanner gauged their brain activity as they did so. The results were extraordinary: when confronted with the expert, it was as if the independent decision-making parts of many subjects’ brains pretty much switched off. They simply ceded their power to decide to the expert.
If we are to control our own destinies, we have to switch our brains back on and come to our medical consultations with plenty of research done, able to use the relevant jargon.
That's a great suggestion, assuming you have a high IQ and your illness isn't cognitively debilitating and you aren't too emotionally discombobulated by being on death's door.
If we can’t do this ourselves we need to identify someone in our social or family network who can do so on our behalf.
That's a great suggestion, assuming your social or family network is full of medical researchers and/or doctors who can give you good free advice on which arcane specialist to choose.
But lots of people aren't that plugged in. What about them?
I've made this suggestion many times before, so I apologize for boring long-time readers, but it's important: You should be able to pay a doctor to help you choose which specialist to bet your life on. That's what I did when I had cancer in 1996-97. Just as I would hire a consultant to help me choose a new email system for my employer, I hired a young general oncologist as my consultant (in the business, not medical, sense of the word) to help me evaluate the three non-Hodgkins lymphoma specialists in the Chicago area.
And here I am, so I guess I got my money's worth. (Actually, I had excellent health insurance at the time, so I got my employer's money's worth.)
I don't really know why this idea is so alien. I've been given the impression that there was something shady and just-not-done about my deal with my consultant. I suspect it has something to do with "professional ethics" -- doctors don't seem to like having patients pit them against other doctors, with another doctor judging them -- but I've never been able to figure out a Google search that would bring up anything relevant to this topic.
Anybody know?
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26 comments:
Really good idea, and it apparently saved your life. I suspect it comes from your business background, but of course lots of people with a business background don't do that. Maybe a business background combined with unusual independence of thought?
If you approach a doctor with this idea, wouldn't he/ she want you as a patient? I don't see how this works without some luck in knowing exactly the right doctor. I think most doctors would reject the approach.
This seems to be the type of idea that could work great if it was common practice, but can't work well if its not common practice, so it will never be tried.
I'm not, shall we say, an uncritical fan of the NHS, but to its credit my GP has been quite prepared to select a "consultant" (i.e. senior hospital specialist) for me. What he can't guarantee is whether the consultant himself will deal with me, or one of his 'prentices.
When I happen to have seen a copy of the GP's letter to the consultant, the GP does seem to have done a noble job of trying to wangle the business in my favour.
Seems to me a Yelp-type website//Amazon-type rating system for high-end medical service providers might be of merit to those of us who might not want to hire/can't afford a medical consultant to do that work also.
Check out MetaMed- it's a new startup that does this, and I know a lot of the people behind it.
Actually I don't think most doctors have a clue how to evaluate doctors either. And they don't know the relevant research either. They are culturally built to accept experts without question.
Doctors still have a better track record than economists. There´s very little that economists can diagnose with accuracy. Or else they´ll be al rich by now.
Under whose care would you place your sick, beloved child: an experienced doctor, who acknowledges that diagnosing illness can be challenging and subject to error, and who admits to having misdiagnosed some cases over a long career; or your girlfriend, smart as a whip, but a layman whose knowledge of medicine is got exclusively from books and not from treating and curing patients?
That's not professional ethics, it's guild mentality. It's why the AMA tries to control consumer genetic information, etc.
Trusting the so-called expertise of "experts" isn't limited to medicine. I'd say anyone with a PhD after their names qualifies for most people. The trouble isn't so much the "expert" as what they are "expert" in, so to speak. For example, anyone calling themselves "experts" in what passes for economics today is someone worth closing your ears to.
Back in the '90s, when my daughter needed surgery as an infant, our pediatrician at the time referred us to a surgeon who was on staff at one of the least known hospitals in a city that is famous for outstanding medical care.
We were immediately suspicious, but my wife called his office anyway to make an initial appointment. He answered his own phone and said he could see us immediately. He had no staff and no patients!
We realized then that our pediatrician was simply doing her surgeon friend a favor by referring us.
We began researching pediatric surgeons and found one -- in our network -- who was a world-renowned specialist in this particular type of surgery at a designated children's hospital. He saw patients from across the globe who came to town for his expertise. And our pediatrician was willing to send us elsewhere!
I realized then that simply accepting a physician's quick referral can be harmful. They aren't necessarily looking out for your best interests; they are simply passing business along to people they are friends with.
Not only did we find the best surgeon possible. We also dropped that pediatrician.
This is what MetaMed is trying to help with.
I think you've identified the "problem" with pursuing your approach: it's doctor against doctor. Feelings get hurt, major egos get bruised, authority is questioned, omniscience is disputed, and ability to charge as if one is God come to earth is impaired.
And what measly thing is on the other side of the tradeoff? Patient care of the little people is improved.
Yeah, you may have saved your life, but you've thumbed your nose at The Swells. I hope you're proud of yourself.
How can you be sure that this extra effort is what saved your life? What kind of lymphoma did you have? Some types of lymphoma usually respond very well to chemotherapy and have low recurrence rates. It may be that the biological properties of your lymphoma with respect to therapy response saved you rather than hiring extra consultants.
Check out http://www.bestdoctors.com/ A friend corralled me into joininhg him in a sales pitch to them to provide some consulting on math modeling and computer simulations. It was the first I'd ever heard of them. They provide exactly the kind of services you're describing on an international level and mostly to very, very rich and well-connected clients. It would have been fun to work with/for them but our sales pitch didn't pan out.
One problem of physician-ranking schemes is that they are biased in favor of academic physicians who work at brand-name institutions. Those physicians may be world experts in certain disease categories, but they may also spend most of their time in a research lab and see patients infrequently. Patients can develop complications after surgical procedures or chemotherapy, and physicians who are more clinically focused are better at managing those situations even if they are not famous researchers.
I think your advice as to choosing a cancer specialist is 'right on'. I hope I never have the occasion to make use of it.
My advice is for those less sick. I have worked with a lot of doctors over the years. I know a lot of medical terminology but that isn't medicine of course.
BREAKING NEWS While writing this little comment my Kaiser doctor called me at home. How about that? I told him I was preparing a message of advice on how to deal with doctors. I also told him the anti-biotics were working.
My advice is: always develop your own diagnosis before you see the doctor. And (part two) be prepared to be wrong most of the time.
Last week I woke with a sore elbow. I consulted Wikipedia and diagnosed myself with Olecranon Bursitis. I wrote my doctor that I wouldn't be coming in to see him. Four days later I was in his office. He drained my elbow and started me on some obscure anti-biotic. A week later and I'm getting better. I can eat again and the fever has broken.
Neither he nor I know how my elbow (of all things) got infected and we probably never will. He has called this sort of thing 'meat and potatoes' medicine. He solves most of these non-life threatening maladies in ten minutes and hurries down the hall to the next patient.
What you pay for in a good GP is not so much their medical school training but their years of experience with hundreds and hundreds of patients.
Forty years ago Peter Drucker proposed solving the doctor shortage by re-training retired business executives as GPs. He thought the most important quality of a GP was mature judgment - what is called wisdom. He proposed he could give former insurance company VP six weeks of medicine and put them in a clinic.
He was wrong but not crazy. About that time the Nurse Practitioner program started up. About 95% of the time a Nurse Practitioner is just as good as a better educated GP - maybe better.
Modern medicine is not about individuals anymore. My GP has a battery of specialists behind him. He pulled in a dermatologist once when during a routine visit I showed him a rash. You take different drugs if you only have a single doctor. My nest door neighbor has the same heart condition I have but he sees a private practitioner - he takes Pradaxa. I take Coumadin and the Coumadin clinics constantly harasses me. That's an important medical service, harassment.
Modern medicine also practices in the presence of the Internet and mass media. TV tries to get you to pressure your doctor to prescribe some drug. Being your own doctor is like being your own lawyer - always foolish. But medicine is systematically wrong about a few things. Some people should drink more for the sake of their heart health. Few doctors will tell you that. There is good reason to suspect that fat in the diet is not very bad for you either. Opiates are not all that habit forming and not that hard to quit. Nicotine is far more habit forming. Many doctors disapprove of marijuana far more than the evidence would argue caution.
You shouldn't expect your doctor to believe any of these things however. Doctors should be conservative.
Albertosaurus
"I got my employer's money's worth."
Your health insurance premiums were part of your total compensation so from the employers view it was just additional salary expense. You may have not had the option to take an increase in your paycheck in lieu of the health plan but you were still "paid" for it.
There was a reference book, Best Doctors in America, which compiled lists of the "best" doctors in hundreds of specialties. How did they do it? By interviewing the top experts at all the top medical schools and asking them who they would choose to do a certain procedure for a loved one? They weren't allowed to name themselves or anyone in their own institution. They then repeated the same question to everyone on the first list to come up with a second, final list which they published.
Unfortunately that book is now 20 years out of date (though you might still find a copy in your local library. When the Internet came along the author's decided to provide the same information for a thousand dollars a pop. But it's not the same talking to someone over the phone who gives you three names as it is to browse the book.
There are lots of "best doctor" sites on the web now but I doubt they are anywhere near as good as that original list. New York Magazine publishes a best doctors list annually for the city of New York, which is probably the closest. Even so, diagnostician is one of the few "specialties" for which there seem to be no specialists.
Steve, how did you evaluate the guy you hired to evaluate other doctors? I've often thought something along similar lines, but in reverse. To select your primary care physician, an internist for example, you want to consult a bunch of cardiologists and oncologists. Ask them which doctors have referred patients to them in time for them to do some good.
There are a few websites where reviews of doctors are posted. A lot of the reviews aren't much good though; a lot of the patients writing them often tend to focus on bedside manner rather than competence. Some of these sites state where the doctors got their degree and how that school ranks, which is useful (I would avoid american doctors with medical degrees from caribbean or mexican schools).
Angie's List seems to be particularly useless when it comes to doctors.
people don't believe me when i tell them your doctor could be wrong, or try to explain that doctors vary in ability just like any other field. they tend to treat the word of the first doctor they see as law, when in fact, there's usually like 5 or 10 guys in the ENTIRE united states who are the guys you should see for any particular condition, and the rest of the doctors in the field are not as good, and could, and in some cases, WILL, lead you astray.
it's amazing how the treatment for any particular medical condition can improve significantly over only 10 years, driven by ONE surgeon who has pioneered a much better procedure, but the average physician in the field is not aware of the change or not knowledgeable enough about it to perform it. a lot of them rely on what they learned in medical school which was the state of the art 20 or even 30 years ago.
i see this all the time in sports medicine, where people just assume every pro is getting the best medical treatment available, and all outcomes are about the same. it's not true. lots of pros on lots of teams are getting the wrong treatments, from surgeons who are paid millions to get it right, but instead are years behind the leader in their field.
when i had to get my left shoulder operated on, i saw 7 guys before i found a guy in pittsburgh who actually knew what was wrong, and he sent me to another guy in boston, who was the leading authority on the condition, and he confirmed the diagnosis. that's not a good rate of diagnosis. 1 out of 8. if i had listened to any of the other guys, one of whom was the new york giant's team surgeon and who examined me in new york, i would have been totally screwed.
of course this goes further when we enter the realm of life and death medicine, where again, there can be like 4 or 5 guys in the whole country who are really versed and up on the latest, best treatments for some medical condition, while all other physicians lag by a decade or more.
it's no different than mechanics, or special effects guys, plumbers, computer programmers, carpenters, or any other technical, get your hands dirty field. the best couple guys can save your life, the average guy might not.
what do you call the guy who finished last in his class at medical school? doctor.
what do you call the guy who finished last in his class at medical school? doctor.
Tee-chur?
Any hints on hiring consultants who can help making correct choice hiring doctor consultants? :-)
Like has been said - very good idea. I'm not sure why it's uncouth, but I will say, I've had that experience - you should not judge me, I'm the Dr. I judge you.
For example, I've gotten blood tests at a physical, some dr's mail me the results, some dr's won't mail me the results. The idea that I would want to look at the quantitative results of my blood tests is uppity somehow. I shouldn't presume to understand the wisdom of the scribes.
(Yes I get why they might be better able to interperet, but at the end of the day, I want the right to make my own evaluations.)
(some examples since you live in L.A.) Steve Jobs Brittany Murphy and one of the Gibb brothers would be alive today if they had been treated by and listened to by a run of the mill below average doctor. Google those three together and eventually you might get some real numbers on the actual unrecounted battle against tricky medical conditions. I am happy for you that there was a chemical weapons accident in WWII era Italy that led to a workable cancer treatment and that you went to several doctors one of whom had a better-than-minimal awareness that a fairly well-known disease might actually be causing your symptoms, but I would not extrapolate from that to a conclusion that any likelihood exists that any significant numbers of sufferers from obscure and perniciously devious diseases are likely to find their own personal M.D. benefactors of humanity - those guys are rare in every profession, even in Louis Pasteur's beloved profession of medicine ... I hope I am wrong, but one might as well expect Brigadoon to pop up in Brooklyn or the Brothers Cheeryble to pay off your credit card debts ....
When I moved my prior dentists advised me to contact a local orthodontist for recommendations on a new dentist. Orthodontists see the work of many dentists.
"The results were extraordinary: when confronted with the expert, it was as if the independent decision-making parts of many subjects’ brains pretty much switched off. They simply ceded their power to decide to the expert. "
I wonder if this tendency increases or decreases as a persons' terminal credential increases (outside of discipline I'd guess is decreases)? I wonder if it correlates to IQ at all (I guess no, or very little).
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