Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together

by Peter A. Ubel

We've all been there, sitting
uncomfortably in a paper gown
as a doctor impassively describes
our prognosis. Sometimes it's simple and
treatable. Other times we get news we
can't fathom and then are faced with
decisions that are literally life and death.





In this revolutionary book, physician,
behavioral scientist, and bioethicist Peter
Ubel, M.D., reveals how hidden dynamics
in the doctor/patient relationship keep
us and our loved ones from making the
best medical choices. From doctors who
struggle to explain, to patients who fail
to properly listen, countless factors alter
the course of our care, causing things to
go seriously awry.





With riveting stories of Ubel's own experience
in the field, his groundbreaking
research, and his personal journey walking
loved ones through difficult treatment
choices, Critical Decisions will forever
change the way we communicate inside
hospitals and medical offices, where
thoughtful decision making matters the
most. Dr. Ubel has been on both ends
of the stethoscope, and in this book,
he shows how patients and doctors
can learn to become partners and work
together to make the right choices. From
choosing to get surgery, to discussing
the side effects of a blood pressure medication,
we can finally discover the tools
to improve communication, understand
the issues, and make confident decisions
for our future health and happiness.

Genres: Nonfiction, Medicine, Health, Medical, Self Help, Psychology

393 pages, Kindle Edition

First published September 4, 2012

About the author

I am a physician and behavioral scientist at Duke University. My research and writing explores the quirks in human nature that influence our lives — the mixture of rational and irrational forces that affect our health, our happiness and the way our society functions. (What fun would it be to tackle just the easy problems?) My goal is to show you, in an entertaining way, why the key to living better, healthier lives, and improving the societies we live in, is to understand human nature.

I’m also a Professor of Business, Public Policy and Medicine at Duke University. (Officially, I’m the – prepare to be impressed – Madge and Dennis T. McLawhorn University Professor of Business at Fuqua.) My research explores controversial issues about the role of values and preferences in health care decision making, from decisions at the bedside to policy decisions. I use the tools of decision psychology and behavioral economics to explore topics like doctor-patient communication, medical decision-making, and healthcare cost containment.

I grew up in Minnesota where I attended an all boys, Roman Catholic, military high school – a definite triple whammy for a horny teenager. Then when I submitted my high school photograph to my undergraduate college, Carleton, and it got posted in the annual book of new students, my classmates decided I was a fascist , leaving me at a decidedly unCatholic, non-military, co-ed college, already shunned. Sigh…

In my spare time, I enjoy classical piano (fanatical about Beethoven and Chopin), chili peppers (both growing and eating them), and sports (when I’m not nursing my most orthopedic injury).

When my now “adult” kids are both in town, we love to spend dinner time playing bridge, the greatest card game ever invented. (Spologies to poker fans)

Reviews

[Pam · Rating 3 out of 5]

Lots of studies and statistics, but it boils down to the fact that you and your doctor have to talk and listen to each other. Ubel shows that the medical field has come a long way in making the patient a participant in their medical decisions, but that there is still a ways to go before communication between doctor and patient is ideal.

[Chrisanne · Rating 3 out of 5]

I absolutely love when patients come into work having "googled" cataracts. Even better when they've talked to their friends. And those that get a second opinion? Fantastic. But not as great as the previous two. If I had money to burn I'd spend every first appointment asking the Dr. what their preferences were... which is sometimes the better question to ask.

This book frankly illustrates the potential issues with making stressful medical decisions. It also illustrates reasons, beyond "they might sue," that doctors should care about educating their patients. He also gives some solid resources for dealing with decision-making, and a helpful list at the back to help patients know what to do.

He overlooks one point, though. Who has money to spend on these extra appointments? Obviously him. But few people and fewer of the people who end up being frequent visitors in the office have that type of money.

I was rather miffed in one thing, though. While he validly points out that one problem might be that MDs and DOs are uninformed when it comes to what patients would prefer, he can't really rid himself of biased viewpoint that patients really don't know what's best/what they want unless they've listened to the Dr. And I didn't like this condescension-ist way of looking at/writing about people. Some (a lot) of patients are really smart. Others just need the knowledge that they are responsible and accountable and they'll step up to the plate.

[Minervas · Rating 5 out of 5]

This is a brilliant book. I've learned lessons that not only can be applied to medical decision-making, but also to communication and decision-making in everyday life.

What defines a good medical decision? In the past, Americans largely believed such decisions belonged exclusively to authoritative, knowledgeable, and benevolent doctors. However, since the patient autonomy movement began in the mid-1970s, people have increasingly recognized that each patient brings unique preferences, values, and life circumstances that doctors may not fully understand. This shift led to a new standard in healthcare: "informed choice." In this model, doctors present patients with various treatment options and explain potential outcomes, empowering patients to make decisions aligned with their personal preferences and circumstances.

In theory, this model should resolve issues in medical decision-making. After all, if patients are equipped with the right information, shouldn’t they be able to make the best choices for themselves?

Peter Ubel, a medical ethics researcher with deep insights into human behavior, challenges this assumption. He argues that human decisions are often influenced by emotions and irrational biases. In practice, patients’ choices can be arbitrary and detached from their values, ultimately undermining the value of free choice.

Why does this happen? Drawing on his experiences as an ethics researcher, physician, family member of patients, and patient himself, Ubel identifies several root causes.

First, doctors often fail to convey the right information in ways patients can understand. Immersed in medical training and sometimes inclined to establish authority, they may overwhelm patients with technical terms, overlooking how patients would interpret such information. Having seen many serious cases and desensitized themselves, doctors can also fail to understand the emotional impact of their messages. For example, Ubel describes a urologist who is proud of using the line “it's something people die with rather than of” to comfort patients with prostate cancer, unaware of the impact of the word "die" on patients who are just shocked by a cancer diagnosis.

Second, patients may struggle to imagine the realities of their choices. What does it mean to live with a colostomy bag for life? Or to have a limb amputated? Ubel cites studies showing that people tend to underestimate their ability to adapt to difficult circumstances. For instance, patients with end-stage kidney failure, despite having a high mortality rate, often report positive moods comparable to healthy individuals. Without this understanding of human resilience, patients may reject treatments that could be beneficial.

Third, medical decisions often involve numbers and probability that patients cannot intuitively grasp. The same statistic can feel vastly depending on how it’s framed. For example, when women are asked to estimate their likelihood of having breast cancer before learning the actual figure (say, 13%), their attitudes toward screening can shift dramatically. This is because the single number, 13%, will feel differently if compared to an imagined number, say 40%. When doctors leave patients to their own devices in figuring out numbers, they often behave in ways that seem irrational, such as being scared away from treatment by rare side effects.

Fourth, medical decisions heighten people's emotions, which in turn affect their decisions. For example, researchers have found that patients favor drugs with names that are easy to pronounce, because it reduces their anxiety. This can partly explain why patients favor expensive non-generic drugs. The issue of heightened emotions is most notable in end-of-life medical decisions, in which patients can cling to unrealistic hopes, interpreting "a response to chemo" as "cured". Doctors are also not immune to their own emotions. Ubel uses himself as example. When he feels down about patients' awful conditions, he would try to find ways to make them feel better, by putting off difficult conversations, dismissing patients' pessimistic prognostications, and offering absurd and inaccurate clichés.

So, what can be done? Ubel offers practical advice for patients, doctors, and healthcare institutions.

For patients, the number one piece of advice I learned is to be proactive and open with doctors. Patients should ask clarification questions and express any fears or confusions. They should share what they care about; otherwise, doctors won't be able to make recommendations that align with their values. To help envision difficult outcomes, patients should seek out people who are in such situations and ask concrete questions. In addition to getting informed about probabilities, patients should seek out decision aids for better interpretation of risks.

For doctors, Ubel advocates for attentiveness to patients’ emotional states, allowing them time to process information rather than rushing through. Moreover, he believes that doctors should not only be passive information providers. Instead, they should recognize the challenges encountered by patients in decision making, and share the burden together actively. Using his experience with a prostate cancer patient, Ubel demonstrates how doctors can help guide patients through choices like “trying on” options in a changing room, giving them the space to discover their own preference and see what medical choice feels right.

For medical institutions, Ubel argues that training should include behavioral science and emphasize "less on how molecules work and more on how humans behave." This shift, he suggests, benefits both patients and doctors, as improved communication has been linked to fewer medical lawsuits

This is a thoughtful, well-written book, rich with compelling stories and research findings. I found Ubel’s insights inspiring, encouraging me to approach all forms of communication with greater mindfulness: to consider emotions and irrational tendencies of myself and others, provide contextual information, listen actively, and share the decision-making burden.

[Ross Mckinney · Rating 4 out of 5]

It isn't often the case, but I know Peter Ubel, the author, so I'm a bit biased. I think Peter's done a nice job of summarizing important lessons that he and other researchers have learned about how we can improve communication between physicians and patients. I'd say as a whole he's done a very solid job, but this is still an evolutionary time. The revolution was patient empowerment, and we're still trying to figure out what to do with it. Peter has a range of good suggestions, but I'd judge he's still searching for what works, as are many of us who take care of patients and care about communication. Some of the book is quite potent (his personal insights, particularly), but the last few chapters don't quite "bring it home" to a tight conclusion. Worthwhile and recommended.

[Catherine Mustread · Rating 3 out of 5]

Info about things to consider when making a medical decision along with some case studies and history of medical decision training.

[Leslie · Rating 5 out of 5]

Ubel has taken a survey of the tremendous body of work he and a lot of other talented researchers have amassed in the decades since he became a physician. The book is a unique blend of bioethics, medicine, psychology, and behavioral economics, among other areas of study.

It begins with an historical overview of bioethics, beginning with Hippocrates, and details why the wisdom of the ages suddenly became inadequate for responding to the environment of modern medical practice. He details the rocky history through which these inadequacies were discovered: individual patients who received treatments they never would have chosen due to paternalistic biases of their physicians, violations of the rights of people involved in medical research due to unrecognized conflicts of interest of participating researchers, and day-to-day heartache during medical crises due to poor communication between patients and physicians.

Ubel does a masterly job of explaining complex concepts clearly. He explains all the ways that cognitive biases and emotions alter our processing around medical diagnoses and treatments. And he provides helpful ways for patients to prepare themselves to meet these biases, and to communicate as effectively as possible with physicians.

The book ends with a vivid illustration of the challenges we face going forward. Ubel details the difficult decisions he and his wife faced - and even some they were not informed about - during her recent diagnosis and treatment for breast cancer. When the most prepared and empowered people face such difficulties, it is obvious how far we have to go. Fortunately, lots of patients and physicians are committed to helping the cultural change to occur. When we get there, the norm will be true collaboration between patients and physicians to make the best decision for each individual - shared decision-making will be a reality.

[Paula · Rating 4 out of 5]

While not a nail biter- This is an important read for everyone. facing a serious medical threat is something we will likely all have to deal with at some point in our lives- be it our own or with a loved one. I read it out of curiosity and it still held my attention throughout. Its not exciting, but it is very interesting, It contains a lot of data about how decisions are made in the human brain based on the information presented, how our brains respond to threats and how Doctors view the dissemination of that information and what is going on in their brains too. Maybe I was so fascinated because I was closely involved in my father's medical decisions at the end of his life, often going to Drs appointments with him and could relate- I wish I had read this book then. Even if you haven't been in that situation, chances are one day you will be, either making your own decisions or helping a loved one. If God willing you never are, its still fascinating how human brains work on both sides of the examining table, and how imperfect medical science really is. That imperfection maybe the most important lesson learned in this book as we look to doctors for guidance. Imperfect information, varying results based on individuals, our imperfect brains clouded with emotion and our doctors who are human too- its a very dynamic relationship between patient, loved ones, providers, researchers and administrators- all of whom are human- who are involved in the very emotional decision making involved in what could be life and death decisions.

[Amol · Rating 5 out of 5]

Critical Decisions is a phenomenal read; in an ideal world, this would be issued to every healthcare provider and patient as mandatory reading.

The fundamental premise is this: in today's healthcare system, we have this ideal of shared decision making, but what does that really mean, and how do we operationally put that into practice? How did the concept of patient-centered care and participatory medicine come to exist? How can doctors let patients' values and interests drive clinical decisions while incorporating their own experiences and knowledge? What are some ways that our perceptions and behaviors affect the way we understand risk, compare anticipated outcomes, and make choices?

For healthcare providers, Critical Decisions is a great balance of clinical ethics, behavioral economics, and medical humanities that will certainly inform the way that you make decisions with patients in daily practice. As an EMT, I've found it informative for my daily work. Likewise, for patients, I expect that this book is a guidebook to understanding how your doctor thinks and communicates, and how you can be a more engaged advocate for yourself (or for a loved one who is a patient).

Excellent, excellent read that blends theory and practice well and speaks to a broad audience of diverse interests.

[Pr Latta · Rating 4 out of 5]

Ubel's very accessible book takes us historically through the patient empowerment movement, explains the research that has nudged the medical field toward more collaboration, makes concrete suggestions at the end of each chapter. The book is clearly written, well organized, at time humorous, melding what could be dry research with case studies and even personal experiences resulting in a very readable, though-provoking, and possibly empowering book but ultimately left me feeling the field is still evolving and incomplete.

I discovered this title after reading Leana Wen's https://www.goodreads.com/book/show/1... -- a more personal "how to" take on the topic.

[Katherine · Rating 4 out of 5]

Peter Ubel is a physician who specializes in ethics, and does research in communications between doctor and patient. In Critical Decisions, he discusses the background of the patient rights movement with examples most of us will recognize - Karen Ann Quinlan, Betty Ford's breast cancer - and efforts to empower patients to make their own medical decisions. According to Ubel, clear communication is the key.

Well-written, with the right mixture of personal stories and research analysis.

[Chelsea Lawson · Rating 4 out of 5]

I found this book very entertaining and worthwhile to read. It tells the story of how our society went from 'doctor knows best,' to 'doctors should just give patients information to make their own decisions,' to hopefully a future of shared decision making. It uses a lot of anecdotes and some behavioral psychology of decision making. I found those parts kind of redundant because I've learned a lot about it but over all I'd recommend the book if you have an interest in healthcare.

[Crescens · Rating 4 out of 5]

Dr. Ubel is a general physician & bioethicist who uses behavioural economics and decision-making psychology together with real life scenarios to convince us (both doctors & patients) that we need to work harder to make the most appropriate & satisfying medical decisions. But I'm still not convinced that we need less time in basic science and more communication subjects in med school! No way, if that means more essays and pretend patients to pass the course (am not a fan).

[Ileana · Rating 5 out of 5]

http://www.jopm.org/media-watch/books...

[Ellie · Rating 4 out of 5]

I would recommend this one to friends outside and inside the medical field.

[Denise · Rating 3 out of 5]

How can we use behavioral science to help doctors and patients engage in shared decision making? This book has many examples of methods developed to get to this goal.