Friday, March 9, 2012

The Lake Woebegon Effect

There are two very interesting books out about how we, as doctors and patients, approach health care. One, How Doctor's Think gives us insight as to how doctors tend to approach the care of patients. The other, Your Medical Mind , also by Jerome Groopman with Pamela Hartzband, helps us as patients understand the complexities of medical decision making.

One perplexing dilemma I noted over the years in the ICU was the tendency of families to be unrealistically (from my perspective) optimistic about the survival chances of their loved ones. When I'd discuss a probability of a 5% chance of survival, or even less than 1%, in a direly ill patient on a ventilator with multiple organs failing, a family member might understand the poor chances, yet believe that they could beat the odds - much I suppose like the Las Vegas gambler except the stakes were so much higher in the ICU.

Educators are familiar with the Lake Woebegon Effect, in that when surveyed almost all feel that their students are above average. When it comes to health care in the ICU a recent study confirmed that families tend to have an optimistic bias. This, of course, seems natural when you think about it. Not wanting to lose a loved one, we martial all the resources to keep them alive - including an optimistic bias about the facts presented to us. To me this at least in part explains the very difficult process of shifting from full bore heroic ICU care toward palliative symptom control.

Part of it may be a doctor's reluctance to use such words as, "Your wife is dying and we are doing everything possible to make her comfortable, but I don't recommend attempts to attempt CPR or heart shocks which may cause pain and which would be ineffective."

The more we can understand the psychology of medical decision making, the better we will be at end of life care. It is the intersection of philosophy, religion, emotions - and life itself. The complexities of the interactions can be dramatic or mundane - but very human as doctors and patients try to work through the Lake Woebegon Effect.

1 comment:

  1. We need ethics committees that convene automatically in certain cases, particularly those that involve a frail elder. Very often, palliative care isn't even approached. What is informed about that?


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