Here is a very common patient interaction I come across at least once every summer (truncated generic version):
A patient (usually a healthy woman somewhere between 30 and 50 years old) comes in with concern of swollen ankles for a few days. I make sure to assess for significant issues, such as heart failure, blood clots, etc. But her story is notable for eating more tortilla chips and salsa lately – it is summer, after all – and vacationing (traveling via airplane) and eating out more. She has been walking more than she normally does in locations where temperatures reach 90+ degrees Fahrenheit in the summer.
I explain to the patient some of the causes of swollen ankles particular to her case: traveling, gravity, salt intake, heat, etc. The patient has skeptical look on face and says something that expresses doubt about my assessment. I explain more about the physiology of swelling in the legs. The patient continues to look quizzical. So I say, “This happens to me from time to time.”
What happens next? Bingo.
Quizzical look disappears. Patient: “OK. So what can I do?”
When I first started practicing, I was very “professional” (or so I thought). What I mean is, I was “all business” during the office visits, focusing only patients’ issues and interests and chit-chatting very little about my own. After all, they were not there to hear about me, right? Futhermore, talking about myself seemed to waste time that was already precious in a primary care physician’s workday. Over time, however, I realized I was wrong and that many of my patients did want to know more about me as a person, and it felt surprisingly nice, especially when it happened organically.
I recently realized that I divulge some of my own personal healthcare experiences now, things I normally wouldn’t reveal in regular conversation with friends. It seems that I have come to do this somewhat subconsciously not so that patients can get to know me, but rather to “validate” my recommendations (see above story). Now, as a – knock-on-wood – relatively healthy, young-ish doctor, I can only draw upon a very limited number of experiences. I am a bit too honest to make up stories. And though I’ve heard countless recommendations by patients that doctors should experience this procedure or that disease – and I completely understand this point – exactly how many diseases does a doctor have to have for his patients to trust his recommendations?
The better question is: What is it about our stories that make them so much more impactful or appealing than medical knowledge or scientific data? This seems to be irrespective of demographic, as I observe in my practice. Male/female. Educated/uneducated. White/non-white. Younger/older. This effect has been demonstrated in all of these groups.
We see the power of stories in advertisements for fad diets or exercise gimmicks. We see it with new mothers who follow their own mothers’ “tried-and-true” wisdom even though it might be contrary to a doctor’s recommendations. We see it when people share naturopathic – or prescription, for that matter – medications with each other. “Try this, it worked for me.”
It can be mind-boggling and frustrating from a data-driven perspective. All this effort towards public and individual education for the empowerment and engagement of patients seemingly gets thwarted by simple, yet impactful, stories by people who have never even taken a biology class. Stories that may not even have any recognizable medical sense to them. This is not to invalidate The Story. (I feel there is a real place and an important role and a certain beauty to it. Stories in fitness magazines inspired me to become healthier years ago.) On the contrary, I am fascinated by the truth of the power of it…and the inadequacies of statistics and data in everyday clinical situations.
Data and statistics are most effective when gathered and used by objective individuals. They seem to lose relevance when we become the subject. When we are the ones with something even as simple as a sore throat, objectivity might fly out the window. And when we are the ones with illness, sometimes the underlying emotional/psychological aspects of our decision-making become amplified. For example, if we tend toward positivity, we might hear the success rates or the benefits more than we comprehend the risks. If we tend towards pessimism, we might lean towards the gloomier side of the medical equation, even if the chance is 50/50. If our nature is to overreact or always imagine the worst, we might dwell on the rarest side effect/outcome of a medication/disease. And, interestingly, sometimes the seemingly objective patient is one who is in denial.
This reflexive loss of objectivity when faced with a personal dilemma is such a human trait that it even applies to the very people who are trained to be medically objective – doctors. For example, a physician friend of mine was ill for a few days and asked my opinion on whether she needed antibiotics. Based on her reported symptoms – and without offering specific recommendations, as I did not examine her – I simply asked her if she might be reaching for antibiotics a little prematurely. She agreed that maybe she was. She needed a reminder to take a step back and reconsider her symptoms a little more objectively. I myself don’t feel I’m immune to this tendency though I am writing this post. Even though I might be able to treat myself for various things, I see my own primary care doctor for her assessment. I make sure to voice any worry that I might have about an issue, but I trust that she will remain objective, at least more so than I would be at that moment.
Statistics and data can be unglamorous. We can articulate them with various vocal inflections, but they are – (close your ears, statisticians) – still numbers, which do not have the same significance for everyone. But we do know that stories can last forever. They play over and over again in our minds. The story of the apple falling on Newton’s head was never true, but we as a society have held on to that image. It fulfills something within us. Religions “know” this. Cautionary fables, present in many cultures, reflect this. Modern medicine doesn’t. How do we make the data and statistics and the objectivity of our field more influential? Do we even need to? How do we as physicians “convince” patients to follow our recommendations? What do you think, fellow doctors? Patients, what was the most helpful thing your doctor did when you were faced with a difficult decision? I’d love to hear your thoughts.