Understanding Your Medical Mind Through the Lens of Jewish Tradition

To find ways to help people decide on the treatments best suited to their temperaments, DR. JEROME GROOPMAN and D R . PAMELA HARTZBAND considered many paradigms, including Jewish traditions

by Jerome Groopman and Pamela Hartzband

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Every day we are flooded with information about our health. Pick up a newspaper or magazine, turn on the radio or television, log onto the Internet, and you’ll be sure to see advice about a medical issue. It can be overwhelming and confusing, especially because the experts often don’t agree. So how can you decide what is best for you?

For an answer, first we looked at standard decision-making strategies that are widely used in economics. This approach is based on mathematical formulas. While these formulas have been applied to medicine, they are deeply flawed because the complex and changing nature of the experience of illness cannot be reduced to numbers.

So next we looked for an answer by interviewing scores of patients from across the country who had different medical problems. They came from different socioeconomic groups and different religious and cultural backgrounds.

We discovered common patterns that reveal how each of us views what is best. Some people want to be proactive, to do everything and more. We call these people maximalists. Others think that less is more and want the least treatment; these are minimalists. Then there are those who turn to natural sources for possible remedies, such as herbs, acupuncture, and supplements; they have a naturalism orientation. On the other hand, people with a technology orientation look to modern science for the latest cutting-edge procedures or medications.

Finally, we found people we call believers and others we call doubters. Believers are convinced that there must be a good solution to their problem and it is just a matter of finding it. Doubters are deeply skeptical, focusing on side effects and unintended consequences. They worry that the treatment will be worse than the disease.

In our recent book, Your Medical Mind, we draw on these categories as well as on new research to set out a novel framework to help people figure out what is best for them. While we believe this framework is universal, here we will explore how traditional Jewish principles apply.

Each day in the Amidah we thank God for giving us daat (knowledge), binah (understanding), and haskal (discernment). Each of us has the ability to engage information, grasp it, and then weigh how to use it in our lives. The same sequence illustrated by the Amidah can guide us in navigating the flood of medical information. You initially obtain current knowledge about a medical issue, then understand the numbers, and finally discern what applies to you as an individual.

It is easy to be misled by the way numbers are presented or framed. For example, in our book we recount the experience of a woman we call Susan Powell, who had an elevated cholesterol level, a very common health issue. She was in her 40s and had no other risk factors for heart disease: she did not smoke, had a normal blood pressure, was not diabetic, got plenty of exercise, and followed a healthy diet. On a routine checkup, her primary care physician told her that her cholesterol was elevated at 240 – the normal cutoff is 200. Her doctor recommended that Susan take a statin medication, telling her that it would reduce her risk of a heart attack by 30 percent.

Hearing that the drug would reduce her risk of a heart attack by 30 percent made a deep impression on Susan. But Susan was a minimalist and a doubter, and did not immediately fill the prescription. Over the following months, she looked for more information and found a government website that helped her assess the state of her health. She entered her age, gender, cholesterol level, and other data, and saw that her risk of a heart attack over the next 10 years was one percent, or 1 in 100. This is the answer to the key question every patient should ask: What is my risk of a problem in the future if I take no treatment at all? For women like Susan, if 1 in 100 women has a heart attack, that means that 2 in 200 or 3 in 300 would. Reducing the risk by 30 percent would protect 1 of the 3 out of 300 expected to have a heart attack; 2 women still would have a heart attack, and the remaining 297 would take the statin medication with no apparent benefit and be at risk for its side effects.

This kind of simple calculation comes as a surprise not only to most patients but to many physicians. When we hear that a drug reduces the risk by 30 percent, we assume that we are at 100 percent risk for a heart attack, and the 30 percent reduction appears very large. But that is not actually the case. Rather, the drug reduces the risk of 1 in 100 by 30 percent, which clearly has a much smaller impact on our thinking. Now, for someone who is a doubter and minimalist, like Susan, that degree of benefit would not appear worthwhile given the risk of side effects of muscle pain and indigestion. But another patient who is a believer and maximalist would say, “I may be the 1 in 100 destined to have a heart attack, so taking the pill and reducing the risk by 30 percent is worth it to me.”

The Jewish tradition encourages us to think for ourselves and to challenge authority. Our rabbi, William Hamilton of Congregation Kehillath Israel in Brookline, Massachusetts, recently gave a dvar Torah about Abraham in which he explained that since our people’s inception, we have been “hardwired for the contrarian spirit.” When God tells Abraham of the impending destruction of Sodom and Gomorrah, Abraham is not silent. Rather, he negotiates with God, pushing the boundaries of the divine injunction, with a focus on the sanctity of each human life.

This tradition of questioning and challenging means that different people can look at the same information and interpret it in various ways. Indeed, the Talmud itself is a compendium of conflicting opinions reaching across centuries. Scholars challenge each other in different generations, and in their debates we see that there is no perfect human authority that dictates one view for all times. The Talmud provides not only second opinions, but third and fourth and fifth opinions!

A primary focus in our heritage is pikuach nefesh (saving a life). In making choices of treatment, we focus on the sanctity of human life and seek what is best for each person, recognizing that each of us can be different both in our biological reactions and in how much risk we are willing to take for how much potential gain.

This weighing of risk and benefit involves a meeting of the minds of the patient and the physician. In the past, a physician was often put on a pedestal – what the doctor said was never questioned. That has changed; in the new model, patient and doctor decide together. This joint decision-making mirrors the concept of chevruta, learning from each other and gaining mutual insights to reach a shared conclusion. In shared medical decision making, the physician first must understand the patient’s mindset, and just as importantly, the patient should be aware of the doctor’s mindset, so that together they can assess the different ways to treat a particular problem. Your doctor may or may not have the same medical mind that you have. Nonetheless, it is essential that your doctor understands and respects your mindset and further that you recognize that the doctor, too, has a particular orientation in approaching medical decisions.

Even though joint decision-making is now the preferred medical model, it is not for everyone. A study of 1,000 women with breast cancer facing different treatment choices found that about 20 percent delegated all decision-making to their doctors; around 30 percent wanted to make most decisions themselves; and half wanted decisions to be made jointly.

When we explored end-of-life decisionmaking – how people can communicate their wishes to family, friends, and physicians when life itself hangs in the balance – it struck us that the framework we suggest is embodied in the mishberach for cholim, the prayer for the sick. Consider the order of the requests in the prayer: refuat hanefesh (healing of the soul) followed by refuat haguf (healing of the body). Engaging the nefesh (soul) means understanding the mindset, the emotions and values, the goals and beliefs, of the individual patient. The medical mind belongs within nefesh, and making end-of-life choices draws on both the medical mind and how it can be linked to the guf, the body.

Finally, we apply to medicine the famous verses from Deuteronomy that teach us that Torah, “this instruction and learning,” is not remote, not far away in the heavens, not hidden in the depths. In making choices about treatment, we should not assume that medical information is so complex as to be beyond our ability to understand it. Our tradition prompts us to make intelligent choices that draw on God’s gifts that allow each of us to decide what is best for us.

Jerome Groopman, M.D. and Pamela Hartzband, M.D., authors of the recently published, Your Medical Mind: How To Decide What Is Right For You, are on the faculty of Harvard Medical School and on the staff of Boston’s Beth Israel Deaconess Medical Center. They have collaborated on articles for The New York Times, The Wall Street Journal, and the New England Journal of Medicine. They are members of Congregation Kehillath Israel in Brookline, Massachusetts.