How Do You Make Decisions in Healthcare? (Talya Miron-Shatz)
“Digital health experts know a lot about health, a lot about technology, but oftentimes they don't know a lot about the psychology of the users, the behavioral economics and ways in which you can motivate them," says Talya Miron- Shatz, PhD, an expert in medical decision making.
The psychology behind decision-making is crucial for companies to be able to present meaningful information to people, not just offer them data people can’t understand.
Motivation and choice are two factors contributing to the success of a treatment or intervention.
“Just giving people information is not enough because maybe they don't understand it. Just telling them what to do is not enough because maybe they're not motivated to engage with an intervention,” warns Talya Miron Shatz.
Leading a healthy lifestyle or managing a disease well depends on various circumstances and factors such as the doctor-patient relationship. The language used by the medical professional, how well is a patient prepared for a medical visit and how many questions does she ask to really understand the things presented to her.If a doctor talks about hypertension, that might be less understandable to the patient compared to high blood pressure. Atrial fibrillation is a loaded term, in contrast to a medical condition that can cause stroke. When doctors talk about probabilities with patients, the advice offered by dr. Miron-Shatz is to talk in a frequentist way. “Instead of saying the chances of something happening are, 0.7 or worse 0.07, say out of a thousand people, seven people will have this condition or side effect or outcome. You decide if that's good or bad for you.” Understanding is the first step towards shared decision-making.
What is shared decision-making in healthcare?
Healthcare and medicine are moving away from paternalism to collaboration with patients. Unfortunately sometimes giving patients the options can serve as a shield for the medical professional in terms of liability rather than helping the patient. Therefore, says dr. Miron-Shatz, good decision making can also be giving the patient the choice in how to make decisions. The patient might not want to make choices, but will rather leave the judgment to the doctor, so she can focus on healing.
Good healthcare should entail shared decision-making where both the patient and the doctor work together to make a decision. However, getting to shared decision-making in practice is difficult, says Talya Miron-Shatz. “To get to that beautiful point of shared decision-making, the doctor has to listen. You have to trust the doctor. You have to feel like they really care about you. Not that they're in love with you, but that they give you the impression that they are there for you. That's a lot. That's actually quite a lot,” she illustrates.
Dr. Miron-Shatz lives between the US and Israel - two countries with vastly different healthcare systems. Do patients make different decisions because in Israel patients don’t have to worry about surprise bills and spend their life with the same healthcare provider (HMO)? “I sometimes tell my students in Israel that there is a higher chance people will get a divorce in their lifetime than change an HMO,” says dr. Miron-Shatz. This enables continuity in individual care. In the US in contrast, healthcare providers can change every few years for a person, because the employer changes providers. Or the individual changes her job and is then covered by a different healthcare provider under the new employer.
The factors of trust and decision making
Dr. Miron-Shatz was the post-doctoral fellow of Nobel Laureate Daniel Kahneman (the author of Thinking Fast and Slow) at Princeton University. As she says in general, we like to process information quickly, based on cues, not too much information. Healthcare is often no exception. “When we go to see the doctor, we say, oh, the doctor looked professional, he is a good doctor. Is he really a good doctor? I don't know. I need cues. I need hints. Medical information is very dry. It's very complicated. It's the opposite of giving us hints. Daniel Kahneman talks about system one and system two thinking. System one is quick and dirty. It's oh, this looks great. This sounds credible.”
People make decisions based on emotions, and that is something healthcare policymakers should also keep in mind. She illustrates with the example of a COVID vaccination campaign for children in Israel. “The prime minister here tried to convince parents to vaccinate their kids. He didn't talk about statistics. He gave the word to a 16-year-old girl who had COVID. She used to be a top student and after COVID her cognitive abilities were affected. So now everyone in the country knows this girl and knows how old she is and knows what happened to her. The prime minister used the right language. He did not use a lot of information, but something very emotional. Stories are always more convincing than statistics.”
What to ask the doctor?
Being a patient is vulnerable, which makes it difficult to act as rationally as you would like during a medical intervention. Dr. Talya Miron-Shatz has simple advice about medical visits. Ask about what matters, with the help of these three questions:
What are the risks? Often we don’t want to think about them.
What are the benefits?
What are the alternatives? If there are alternatives, you should know about them. Perhaps physical therapy is an alternative to surgery. Perhaps local anesthesia is an alternative to full anesthesia.
You need to practice these questions because a doctor’s visit might be overwhelmed and by not asking what they need to know, patients google their questions and may not find what they need.
Tune in to the full interview on iTunes, Audible, Spotify.
Questions addressed in the interview:
You recently published a book about this topic - Your life depends on it. What are some of the conclusions that perhaps stand out most to you, after you finalized your decision? What are some of the main messages you would highlight?
What are some of the decision-making weak points you see in patients and in clinicians? Can you name two or three for each group?
Your book offers advice for doctors and patients related to how they can make better decisions and also communicate more clearly. For example, you advise doctors to always talk about representation (1 in 1000) rather than percentages (1% chance)?
Given that you come from Israel: do you observe that people make decisions differently in a private vs. a public system? If we compare Israel to the US - In Israel which has public healthcare, run by 4 Health Maintanance Organisation patients don’t need to fear preauthorization requests being denied or surprise bills arriving to one’s doorstep.
How do you envision successful shared decision-making in healthcare? Not only is making decisions difficult on its own, but it’s also getting increasingly difficult because a lot of conspiracy pieces can be written in a credibly-sounding way.
It’s good if we can make informed decisions, but to what extent is putting the decision-making on patients a way to avoid liability for medical errors?