← Back to July 2017

Words, Books and Patients

links image

Sarah Schettle, PA-C
Mayo Clinic
Rochester, MN, USA

A quick shameless Wikipedia search suggests that 45% of English words derive from French origins. French hails primarily from Latin roots, and Latin is the foundation of medical terminology, linking medical providers together in the end with words being our primary sources of communication. When pondering the concept of words, I immediately recalled several interesting concepts I have read in few recent books, one which ironically was bought to tide me over in an airport delay after ISHLT.

Some Links readers may be familiar with "the jam studies," an interesting assessment of the impact of choices in decision making. Sheena Iyengar in her 2011 book The Art of Choosing, describes the study. Large jam assortment stands with 24 flavors and small jam assortments of 6 flavors were set up on different days at the same grocery store. 60% of shoppers were drawn to the large assortment and 40% to the small assortment. Customers could sample as many jams as they wished, and on average 2 jams were sampled regardless of whether the assortment was small or large. Customers were tracked using $1 discount jam coupons. 30% of those with coupons in the small assortment group bought jams, but only 3% of those with coupons from the large assortment group bought jam. It was concluded that "when people are given a moderate number of options (4-6) versus large number (20-30), they are more likely to make a choice, are more confident in their decisions, and are happier with what they choose." It may behoove us as clinicians to remember such things when presenting our patients with options as a way to improve their satisfaction in making complex medical decisions.

Amos Tversky and Daniel Kahneman published interesting data regarding framing effect, or reactions based on gains or losses. They reviewed two groups of individuals potentially facing surgery or radiation for whom data was presented in terms of survival (i.e. (A) 90% survive surgery and have a 34% 5 year survival or (B) all survive radiation treatment with a 22% 5 year survival after) or presented in terms of mortality (i.e. (A) 10% die with surgery and 66% have died 5 years after or (B) 0% die with treatment and 78% died 5 years after). Interestingly, and perhaps not surprisingly, in the group for whom data was presented in terms of survival, 25% preferred radiation to surgery, whereas 42% of the group for whom data was presented in terms of mortality preferred radiation to surgery. The authors note, "when the possibility of dying during surgery was highlighted, people were more likely to select radiation therapy, even at the cost of decreased survival." Criticisms of these findings suggest that implied consequences may unfairly bias participants. Regardless, the concept certainly is thought provoking and may play a role in how we could approach informed consent for medical procedures.

Joseph Hallinan, author of Why We Make Mistakes: How We Look without Seeing, Forget Things in Seconds and Are All Pretty Sure We Are Way above Average, describes a study of colostomy patients at MI medical center. Some patients were told there was a possibility of reversal in the future, some were told they would have a permanent colostomy. Overall life satisfaction over 6 months was tracked. Perhaps surprising at first was the finding that permanent colostomy patients were happier, improved more rapidly and were better adapted than the cohort of colostomy patients with possible reversal who remained relatively unsatisfied. Hallinan notes that, "hope impedes adaptation…if you're stuck with something; you learn to live with it. And the sooner you learn to live with it, the happier you will be." I found this particularly thought provoking in the context of mechanical support device patients and the categorization of patients as bridge or destination therapy and how waiting for a transplant that has not yet been realized compared with permanent therapy may affect overall satisfaction.

Schooler et. al. published an article in Cognitive Psychology in 1990, aptly titled, Verbal Overshadowing of Visual Memories: Some Things Are Better Left Unsaid. He categorized individuals into two groups both which were shown paint swatches. The first group was asked to describe the paint color and the second group was asked to merely look at the paint swatch. Afterward, both groups were shown 6 swatches and asked to pick the original paint swatch that they were shown. 73% of non-describers were correct compared with only 33% of describers who were correct. He concluded that "verbal descriptions of experiences can overwrite memories of experiences (thus) remembering not what they had experienced but what they had said about what they experienced…we reduce experiences to words." Verbal descriptions from memory of a past event, treatment or hospitalization are merely recapitulation of what we recall a memory to be. This may be worth noting as we all can recall patients who relive their medical experiences and perhaps in a way, end up with the memory that they want.

These and many other books and articles have caused me to pause and assess how I offer care and treat patients. Overwhelmingly, patients with options may result in dissatisfaction. Rather than clearly offering fewer options, phrasing surgery in terms of survival versus mortality may impact what my patient may choose, and hope may be a double edged sword in some situations. How fortunate we all are to have patients place their life and care to us as providers, and it is my hope that we all consider the responsibility that this entails and remain good stewards of our patients trust and confidence. ■

Disclosure Statement: The author has no conflicts of interest to disclose.

Share via:

links image    links image    links image    links image