Decision-Making in the Doctor’s Office with Dr. Talya Miron-Shatz

The changing landscape of physician-patient interactions

“It used to be that the doctor had all the knowledge about the medical issue, you had the knowledge about your body. And there was a very clear distinction. Nowadays, there’s so much information that’s available to us.”

Considering evidence when making health decisions

“I think far more prominent now with COVID that evidence, it just flys out the window. It’s like, I don’t want to see the evidence. I want to hold on to my views. And my views are tainted by my politics, which is not necessarily relevant to how my body reacts to a virus.”

The confirmation bias and its effect on decision making

“The confirmation bias means that you have an answer. And now, you look for evidence. And you can look for evidence in many, many places because we’re living in an era where there’s an explosion of information. So, you look for information, where you will find information that proves you are right. In other words, you can call it an echo chamber. You go into your own echo chamber.”

Depletion and decision making

“There’s the concept of depletion. You will notice that at the end of the day or at the end of a shopping expedition, where you made a ton of decisions, it’s hard for you to decide even on a pizza topping.”

Brooke Struck: Hello everyone and welcome to the podcast of The Decision Lab, a socially conscious applied research firm that uses behavioral science to improve outcomes for all of society. My name is Brooke Struck, research director at TDL. And I’ll be your host for the discussion. My guest today is Talya Miron-Shatz. That’s Talya, with a Y. She’s the CEO of CureMyWay. She’s a visiting researcher at Cambridge and she is the author of the upcoming book, Your Life Depends On It: What You Can Do To Make Better Choices About Your Health. In today’s episode, we’ll be talking about health decisions, the facts, the fictions and the biases that stand between us and good health. Talya, thanks for joining us.

Talya Miron-Shatz: My absolute pleasure.

Brooke Struck: Please tell us a bit about this upcoming book, what is it that’s keeping us awake at night stand? How is this book going to help us?

Talya Miron-Shatz: Sometimes we have to make health decisions and we are really not sure what to do. And I believe many of us are experiencing this with vaccinations right now with COVID. I mean, COVID really just put a huge medical decision in our laps and has made it front and center of our lives basically. For some, this is the case. For others, it’s a disease. It’s a medical condition, someone has cancer, they don’t know what to do, what treatment to take on – or it can even be knee surgery, should I have the surgery? Shouldn’t I have the surgery? And that can definitely keep us up at night. 

There’s another thing that might keep us up. And that is when a loved one needs help, when a loved one, for example, is near the end of their life and it’s such a downer. And even when I say that I’m like, “Oh, nobody wants to hear about it.” But you know it does happen. So, when this happens and you have never spoken about it, then how do you decide? And how do you choose? And to what degree are you going to torment yourself over your choices?

That’s what’s keeping us at night. Some things don’t keep us up at night, but they should. And those are when we make health decisions based on not enough information, or based on emotion. I want to say on a whim that’s not nice. So, I won’t go there. But based on too little information, too little examination, too much hope perhaps or too much fear. And you can say, well can there be too much hope? Emotionally, no hope is amazing. But if you attach hope to something that doesn’t lend itself evidence wise to that much hope, then you should be up at night wondering, “Am I doing the right thing?”

Brooke Struck: In the book, you describe changes in the healthcare system that I think are really relevant here. And that is about the role of the patients in making medical decisions. Once upon a time, patients played a much less active role in decisions about their own health. Can you describe the system before versus what it looks like now?

Talya Miron-Shatz: Of course. We used to work with a more paternalistic model, which means go to the doctor’s, you describe what you have, and they tell you what it is and what to do. End of discussion, if ever there was a discussion. Things are changing, things are changing in a way that we are given much more choice. We are given much more control over our health and our health choices. 

I start with an example from Starbucks, we’re just talking about how many Starbucks branches there used to be versus how many there are. And the endless options that you will have at Starbucks. And we get used to that. So, we get spoiled for choice. And we learn to expect that and to expect that sense of control when you go in and you order a coffee, when they’re going to say, small Americano with no milk and tall green tea latte for Talya, and that’s a completely different beverage that we created. We have control over it. That’s great. When you’re consuming a beverage. It’s really hard when you are having to decide over your health, that’s one aspect of it.

Another is really a legal aspect. I’m not a legal professional but it is hard not to notice that fear of lawsuits is there. It’s almost an elephant in the room. Even when a doctor thinks that you should do something, they will say, “Well, I’m only recommending this. You can choose and I don’t know.” And that’s sometimes it’s not because they really don’t know but rather because they don’t want to be held accountable if anything goes wrong. They want it to be your choice. And that is not easy.

And these things I think were much less prevalent a few decades ago. I have to say some of these things are good. They’re even very good. The fact that you go in and the doctor will say, “Good morning, Dr. Struck. Tell me what’s going on with you. How are you feeling? Why are you here today?” And they really want to know and consult with you. That’s wonderful. That’s a place where we want to be. But where we want to be is really such an important guideline, because if you want guidance, you deserve to have it.

And that’s one of the things I write about. That actually was a major eye opener for me too. I got a review from Harvey Weinstein, the head of the Institute of Medicine at the time. And what he said was, if people want to share in decision-making, they should have the right to decide how much to share and how much to partake, and to what degree they actually want to have an active role in it. So, we should be able to walk into the doctor’s office and say, “I want all the information and I’m going to decide.” Or, “Give me the information and let’s think about it, and talk about it.” Or, “Can you tell me what’s going on? And could you make the decision for me because I don’t know enough about this, or I am really scared. And I’m in pain, and I’m anxious.” And none of these things lend themselves to good decision making. And that’s your absolute right to feel this way.

Brooke Struck: So, I identified two of the drivers there that have pushed this change forward. The first that you mentioned is this expectation on our parts that we will have choices, that we will have lots of choices to make, and that we’re expecting something more personalized. As you were describing the scene at Starbucks, that reminded me of a funny scene from a movie, a Steve Martin movie, L.A. Story, where essentially, they’re going around the table and all the patrons at the table are ordering their coffees, and each one is trying to one up the other in like how elaborate their coffee order is, right?

It’s not just about the barista expecting me to give my order, it’s like, I also feel this social pressure that I should be expecting something personalized and something totally unique to me. So that’s one of the pressures that you talked about. A second pressure is the increasing legal accountability and legal scrutiny of the medical profession. I think certainly the United States seems to be, let’s say, a world leader in many things, including litigation of doctors.

But this is a pattern that is playing itself differently in different jurisdictions around the world about the way that that legal accountability is playing out. But my perception is, as you say that like everywhere around the world, it’s more than it used to be. And then, there was a third thing that you mentioned that stood out to me that I was hoping you could unpack a little further. And that’s about the availability of information. So, what you said is you walk into the doctor’s office and you ask the doctor to give you all of the information about the choice that you’re about to make.

But what really came to my mind is that, from the anecdotal evidence of a number of friends of mine who are medical doctors, there are lots of people who are not waiting for the doctor to provide all of that information. There are people literally walking in with stacks and stacks of medical papers that they’ve printed out and highlighted very thoroughly. So, we also have access to a lot more information than we had previously. Can you talk to us a little bit about how that’s changed the dynamics between patients and doctors?

Talya Miron-Shatz: Incredibly. That is how. It really has, because it used to be that the doctor had all the knowledge about the medical issue, you had the knowledge about your body. And there was a very clear distinction. Nowadays, there’s so much information that’s available to us. And you gave really a wonderful example of people being able to drill down all the way to the latest medical knowledge and research, and studies, and study protocols even that have not yet been fully published and peer reviewed. It’s all out there.

When your friends who are medical doctors describe that, I think it depends who is walking in and to what degree they understand the information. And to what degree they realize that the treatment that they’ve read about actually doesn’t apply to them because they have a different variant, for example of breast cancer. It’s not what they have. It doesn’t apply to them. I think we run the gamut of people being on one hand incredibly empowered with information really being able to find clinical trials that they could not have found before or suggest things.

And actually, I have a story. And I’m not going to tell it here. But it’s a story about the Zumba disease that my daughter was suffering from and managed to cure on her own with information from the internet, and that her doctor didn’t bother to look up. And if you look up Zumba disease, it’s not there on WebMD, but it is there in my book and you should read it. So, that’s a wonderful example of a patient figuring out what is up with her in a way that is unconventional or the neurologist was incapable of doing or is unwilling to do.

And that’s really, really great. Then you have people looking at all those medical resources and not really being able to understand them. So, I mentioned when we were talking before, that I’m doing a lot of writing. I’m doing a lot of writing on various topics and for various outlets, and one of them is on patient empowerment. And sometimes, it’s empowerment. And sometimes, it’s air quotes empowerment. And I write about, here’s a study and a link, and then they say, “Now, let’s be honest, how many of you opened the link? How many of you had the paper till the end?”. I mean, let’s face it, people who’ve been listening to you for a while know that we have system one and system two types of thinking. And system one is quick and dirty, and is based on little evidence and a lot of emotion. It’s very easy to decide the system one. System two, on the other hand, is the one where you read all the medical papers, and you explore, and you examine, and you weigh the evidence, and you deliberate. It takes more time and more effort.

So, we do have a lot of information available to us, to the degree that we understand it and delve into it. It can really guide our decisions. But we also have to remember that a lot of the information out there is not put out there to educate us and inform us in an impartial way. But it’s just put out there to sell something. And then, we really have to scrutinize it. We really have to look at it. And it was frightening. I read that of the 20 most cited papers on… or medical facts, if you will, on Facebook. About half of them were talking about things that are not medically accurate, that were refuted by medical experts. So, you hear something, you think it’s true, you think you’re empowered, you walk into your doctor’s office, and you’re wrong. You have to be prepared for that.

Brooke Struck: This is I think a very timely subject for us to be unpacking – this idea of non-mainstream knowledge. So, there are a lot of, a lot of flavors of non-mainstream knowledge. For instance, a couple of decades ago, we probably wouldn’t have recognized traditional Indigenous knowledge as something legitimate that you could talk about with a doctor as an Indigenous person. But that has changed, for better or for worse, in my perspective, it’s for the better that we’re thinking about different knowledge systems, not just traditional modern Western sciences, we would call it.

But there are also non-mainstream flows of knowledge that we don’t recognize as legitimate. And those are potentially ones that should stay in that category. So, you talked about information that’s out there not to empower you or not to enlighten you, but to sell you something. And sometimes the thing that they’re trying to sell you is just an idea. This is one of the powerful transformations of social media that we’ve seen in the last few years that what was initially designed to be a very powerful sales mechanism can be conceived off very broadly.

You can sell a lot of different kinds of things. It doesn’t have to be a product. It doesn’t have to be a service. It doesn’t have to be something that somebody pays money for. Selling them on an idea can be incredibly powerful. So, we’ve got so far these two categories of non-mainstream knowledge that we want to legitimate because we feel that there is something robust underlying it there. It simply comes from a tradition that’s been marginalized. The second information where we don’t feel that there’s something robust underlying it.

And so, we don’t want to give it legitimation and the power dynamics that come with that. And then, the third, I think you alluded to as well around the frontiers of knowledge that doctors learn a lot when they go to medical school. And when they finish medical school, they continue to do quite a bit of training to stay on the up and up with the latest discoveries. But it is humanly impossible to remain at the forefront of everything that’s going on in medicine at all times, especially when what counts as the forefront is not even this line that’s drawn in what’s been published in a peer reviewed journal. You have these pre publications that are currently undergoing peer review, and people are arriving with that in their bundles of papers as well. So, from the doctor’s perspective, this creates a big challenge in terms of knowledge management.

Talya Miron-Shatz: Absolutely. And you said so many important things. I want to start with what you said about products. And it’s great because in my intro, I teach consumer behavior. I used to teach it at Wharton. The first class I talked about various kinds of products. A product can be a political candidate. I mean, hopefully, you’re not paying the money, but you are paying with your vote. So, that’s a great example. And obviously, an idea as well. And I think with social media, there is no monetary transaction. But with your likes, with your shares, with your views, with your following, you are paying of sorts or there is some commoditization of that. So, we need to be very mindful of what is happening and why are people conveying these ideas to us. 

I want to draw a few lines here. I think you started with just saying, there’s a lot of information out there. It’s not humanly possible for doctors to keep track of it all. It really is inhuman to read everything. There are so many publications, can’t be done. But when it doesn’t happen, it’s not because your doctor is lazy. And it’s not because your doctor has an agenda or they’re trying to hide something from you. And that is where we get into all sorts of conspiracy theories. You also talked about papers that are still under review and I mentioned study protocols. And sometimes the answer is, I don’t know. So, you read about a study protocol and it has not yet happened, what’s going to be the outcome? The only answer is, I don’t know. So, if I give you the answer, this answer and I’m your doctor, does it mean I’m hiding something? I want to save the HMO money, and therefore I’m trying to dissuade you from joining? Or maybe I’m just ignorant. Or maybe I’m acknowledging that there’s a lot of uncertainty. That’s just the way it is. And if I wasn’t acknowledging that, if I was pretending like I know everything, I would really be lying to you. And I think we need to come to terms with the fact that a lot of times, our doctors don’t know, just because they don’t know.

I think COVID, again, it’s been a major lesson in uncertainty. We really don’t know. People are talking about having long-term data about vaccinations. I think, well, that’s not such a great idea actually. Because there are 650,000 Americans who died of COVID to date. How many more Americans do we need to die? And people around the world before you start trusting vaccinations, and you start vaccinating, if you have not already? I mean, sometimes you can’t have all the data. And that’s really and truly important. 

You mentioned the word that I want to go back to and that is robust. I think robust, really, is a good word to hang on to. Because if you’re sick, what I think you should want is a robust cure. You want something that’s evidence based, whether it comes from a pharmaceutical company or from indigenous culture. If it works, if it doesn’t harm, or if it causes less harm than benefit, you want it. And we are seeing a lot of demonetization so it’s funny. It’s like a double-edged sword. We’re talking about cultural groups that are marginalized and sometimes pharma is being demonized. And people say, “Oh, it comes from pharma.” Yes. Well, if you have a headache, what do you want? Do you want me to bang on your head with a hammer or put you on Novo-Profen? I don’t know. Because it comes from a pharmaceutical company. And if you need to be put under to have surgery, are you trusting the anesthesia that comes from a pharmaceutical company? I hope so because I think having major surgery without anesthesia would be difficult. 

We need to think, is this robust? What are we talking about? What is the evidence? And to look at that. And once we have that as our compass, I think we’re in a better shape, our health is in a better shape. That should be our guiding line. And with COVID, it seemed, maybe it was there the whole time. But I think far more prominent now with COVID that evidence, it just fly-out the window. It’s like, I don’t want to see the evidence. I want to hold on to my views. And my views are tainted by my politics, which is not necessarily relevant to how my body reacts to a virus.

Brooke Struck: With all of the changes in the decision environment for patients that we’ve just been talking about, how have those changes had an impact on behavioral dynamics? So, what kinds of cognitive and social biases, and heuristics are more active now in this new environment than they were previously when there was less expectation of us to participate actively in the decision-making process when we have less information and so forth?

Talya Miron-Shatz: I think, and again, I’m going to stick with COVID for a while, just because it’s such a huge example. But really, it’s the case everywhere. I think confirmation bias. The confirmation bias has never been more prominent than it is now. The confirmation bias essentially means that when you have an opinion, regardless of whether or not it’s well founded, you just have an opinion, it can be just because you’re too hard in passing as you were waiting for the bus or a bit more profound, but it doesn’t matter.

You mostly look for evidence to confirm it. You are basically saying, “No. I was told something. I believe it’s true.” I believe it’s true because just cognitively holding on to a thought is so much easier than being on the fence and saying, I don’t know, I’m undecided, maybe A, maybe B, not sure, not sure. Your cognition wants closure. It wants to know what’s going on. And you want to give it an answer. The confirmation bias means that you have an answer. And now, you look for evidence.

And you can look for evidence in many, many places, because we’re living in an era where there’s an explosion of information. You look for information, where you will find information that proves you are right. In other words, you can call it an echo chamber. You go into your own echo chamber. I’ll tell you a secret. I do that too. For the most part, this is what I do. I think this is what we all do. But is it beneficial for our health? I’m not entirely sure. Essentially, we have this beautiful machine on our necks.

It’s called our head. It contains our cognitive system. But it doesn’t like to work very hard. So, we have a lot of information. And we’re constantly looking for shortcuts. And we’re very emotional people. The confirmation bias is really just one example. Another area where we are, I think encountering that dynamic with the doctor is around just understanding medical terms. Because presumably, you can understand everything and you can learn everything, and everything is online.

So, how can you possibly not know that whatever. But maybe you don’t know. And when you’re sitting in the patient’s chair, that’s not a fun chair to be in, to say the least. And actually, when I was writing the book, I made a point of bringing a lot of examples from people sitting in the patient’s seat, making mistakes, being confused, feeling diminished, who are doctors themselves. It’s not like if you’re the cleaner at the hospital, then you feel diminished. And if you’re the surgeon, then you don’t. Because you could very well be the surgeon feeling as diminished or more so than the cleaning person. So, that’s a power dynamic that we don’t always like, and we don’t always like to admit it, but it happens. And I wrote a funny word in my book. I wrote the word allow. It’s funny because there’s no police, for example, in the doctor’s office preventing you from asking a question, but there’s police in your own head preventing you from asking questions because I mean, you have a PhD. I have a PhD.

We’re supposed to be educated people. I mean why don’t you understand something? Maybe you just don’t understand. Maybe it’s the first time you heard it. I write about just allowing people to ask questions and people to allow themselves to ask questions. And I created a set of questions that’s ridiculously and effectively simple. Because I thought, if we use system one all the time, then that’s what we used. And one of the things that Kahneman and Tversky did way back is they created a way of understanding the world that was descriptive.

It wasn’t prescriptive. It didn’t say, “This is how you have to decide.” Because that just doesn’t work. It was descriptive. It said, “This is how you decide.” Is it perfect? No. But that’s just the reality of it. So, if the reality of how we decide is that we tend to use system one. Okay. Let’s go with system one. So, if we do, let’s prepare to ask three questions. That’s super simple, and you can memorize them. And you can use them in multiple contexts. And I call them to ask about what matters.

And these questions are, what are the risks? What are the benefits? What are the alternatives? I start with risks. Because before you get flooded with a ton of information, I want you to know about whatever you’re being offered to duty. You have got to know that. And knowing that what you first learned has the most impact on you, let the risk be the first thing you hear. You can always weigh it afterwards. I’m never going to tell anyone how they should, what they should decide.

I can just say, “I think this is a good way. This is a good process with which to decide.” So, what are the risks? What are the benefits, clearly? And what are the alternatives? So, the alternatives connect to two concepts we already discussed. One is the confirmation bias. Your doctor says you have to have knee surgery. You say, “Okay. Knee surgery, let’s talk about knee surgery.” Confirmation bias. What’s good about it? And how do I do it? How long does it take to recover? It doesn’t go to the place of the alternative. It doesn’t ask, what else could I be doing? What could they be doing instead? So, to just put the confirmation bias on the shelf for a moment is always a great idea. So, what are the alternatives? And that’s the confirmation bias. But it also connects to that weird word I put in of allow. Because even though we are empowered patients, and even though we feel strong and the power dynamic is no longer such that we think our doctor knows everything and should just sit there and nod, and do whatever they tell us.

We still sometimes shy away from asking about alternatives. Because we don’t want our doctor to be angry with us. We don’t want them to feel like we’re disrespecting them or distrusting them. It’s not a bad idea by the way. You want to be on good terms with a person who is about to cut you up. But I want us to have this in our repertoire to be able to talk about what are the alternatives. Knee surgery actually is a fantastic example. Because there is an alternative to knee surgery. And that is physical therapy. In many cases, that’s the alternative. And for some people, it’s a terrible alternative. Because they would never go to physical therapy, or they would go and it would hurt. And they would just say, “Oh, good. The heck with this. I’m not doing this. It’s painful. Give me something for my pain and just cut me open. Fix me up. And thank you very much. And I don’t want to see the physical therapist ever.”

For other people, they will say, “I don’t want to be incapacitated for a while with surgery. I’m athletic. I’m conscientious. I can do this. I will do this. And I will get better without surgery.” But you never know that physical therapy is an alternative unless you ask about alternatives.

Brooke Struck: One of the things you mentioned much earlier in our conversation that I’d like to bring back here, especially in the context of biases, is about the effect of pain and worry on our decision-making processes. So, how do those things interface with our biases and heuristics?

Talya Miron-Shatz: So, there’s the concept of depletion. The idea of depletion is that our mental resources are like a muscle and they can get tired. If you’ve just run a marathon, first of all, bravo to you. But if you’ve just run a marathon, your buddy says, “Hey, let’s go for another marathon.” And you’re like, “Man, I’m beat. Let me recover.” And your brain reacts in pretty much the same way. So, you will notice that at the end of the day or at the end of a shopping expedition, where you made a ton of decisions, it’s hard for you to decide even on a pizza topping. It’s like enough. And in fact, my good friend who I admired because she’s a phenomenal scientist, Kathleen Ross of Minnesota, did a Meta-analysis on depletion. And found that it’s a thing it exists across studies, across field. It’s there. So, when you have made multiple decisions, you are depleted, and you find it hard to make more decisions. But decisions are not the only thing that deplete us. Pain is also very depleting. In fact, pain hijacks you.

When you’re in pain, you’re in pain. That’s where it’s funny, because even the expression is like you are in pain, it becomes a physical place, where are you? You’re not in your office. You’re not in front of the microphone. You are in pain. And that’s where you are. And that’s all you care about. And likewise, with other physical states, that are hot states that hijack our consciousness, when you’re very hungry, when you’re very hot, when you’re very cold, when you’re very angry. That’s all you are at the moment. And you are in no position to make decisions. So, pain will do that to you. Anxiety will do that to you. And these are situations where you are, I don’t want to say ill equipped, even though it’s a nice pun, but you’re not in the best position to make decisions. And that’s fine. It’s important for me to say that, that’s fine. Because it seems like we’re always expecting ourselves to be so super human, so on top of everything. And sometimes it’s just really difficult.

Sometimes it can’t happen. We have got to acknowledge that. We have got to forgive ourselves for it, not to expect ourselves to be superhuman. And our doctors also have to acknowledge that as well. When you’ve just told someone they have cancer, they’ve just lost their hearing. They have gone deaf. They can’t hear anymore. They’re just processing this major thing you’ve just landed on them. This is not a good time to discuss 13 options of treatment, because they cannot process it. And this really is something to take into account. Because I think with all the information that we have, with all the talk about control and empowerment, we sometimes forget that we’re humans, that we’re feeble, that we’re scared. And that it’s fine to be all of these things

Brooke Struck: I really like that example that you just gave. Because I think it so nicely shows the interface of different biases that are going on in the room. You’ve mentioned a couple of times through the conversation that biases are something we all suffer from. And it’s one of the things I find interesting working in a behavioral insights shop, is that often, we can find ourselves defaulting down to this language of these biases or heuristics that they suffer from.

When actually, these biases and heuristics that we suffer from. It’s all of us. It’s not just them. Learning about it doesn’t undo it. It doesn’t break the spell. So, the solution then is not to try to suppress your biases by sheer force of will. That’s not a very winning strategy. It’s about working with them, understanding how they operate, and in a certain sense, submitting to them to just acknowledge that this bias is happening. And to find strategies that allow you to make decisions under better conditions, better decision-making conditions.

And the reason I bring this up and the interface of different biases that are happening in the room, you mentioned this circumstance with the patient sitting in the chair and just learning that they have cancer or some other serious ailment. That’s a very, very massive weight that’s landing on them. It’s very difficult. It’s very challenging at a cognitive as well as an emotional level. But it’s difficult emotionally for the doctor as well. They are submitting themselves to this intense turmoil that’s happening just across the desk from them. So, when you tell the story about the doctor who hits you with this massive news and that immediately launches into the laundry list of options. How much of that is an expression of the doctor’s own bias that they feel this discomfort just witnessing someone go through a difficult emotional moment. And in order to avoid that discomfort, which they may never consciously identify or acknowledge, in order to avoid the discomfort, they immediately go back to their place of comfort, which is like, “I’m an expert. I feel confident about these things that I can speak about.”

Also, with the well-meaning intention, like I’m presenting these options because these are things that I can do to help this patient. So, I want to be there for them. I want to support them. But not necessarily realizing that that type of support is not what the patient might need in that moment, that what they might need in that moment is more of just compassion or potentially a patient’s for giving them space to just process what it is that you’ve just told them. Where is it that the doctors’ biases come in to the decision-making equation and the way that they approach patients in the way that they either amplify or attenuate the biases of their patients? Can you share some examples with us of that?

Talya Miron-Shatz: Of course. I’m really glad that you asked about the doctors’ perspective. I started out writing the book and writing a book is a journey. I went on this journey thinking I was going to write about patients’ decision processes. Then, I realized that everything that happens to the patient also happens to the doctor in two ways. I mean, the first one is that if the patient doesn’t understand, then the doctor is dealing with someone who doesn’t understand. But also, more profoundly.

So, if the patient craves a relationship with their doctor, the doctor also creates a relationship with their patient is nobody went into medicine in order to stare at HRs all the time. So, with the cancer example, or anything where a doctor just gives the patient information that’s hard to process, I think, from the doctor’s perspective, they did go into medical school to help, to heal, to provide cure to the degree that they can. And it feels very debilitating when they can’t do that. So, when they give you options, it’s either because they don’t know how to deal with your emotions or because this is how they can best help. I write about it in the context of end of life discussions, which rarely happen. And they rarely happen because the doctors feel that they are failing their patients, if they tell their patients, you’re going to die, especially. And going back to uncertainty with certain conditions like specific heart conditions, where a person might die within three days, six months or 10 years.

So, what do you tell them? And again, you’re not going back to what we talked about before with uncertainty. If your doctor gives you that diagnosis, and the prognosis is unclear. You could get very angry with them. You could say, “What kind of a doctor? This doctor is not professional. Don’t they know? What do you mean? Three days, six months, 10 years? Are you kidding me? Give me an answer. I need a better doctor.” There are no better doctors. That’s the best doctor in town.

It’s just the reality. So, we have to come to terms with that. And our doctors have to come to terms with that. It’s not a failure to say I don’t know. It’s just reality. You said something else about how we all suffer from biases. And I want to relate to that in two ways. Yes, we do. Biases come from your heuristics. They come from our very innate tendency to use heuristics, which are mental shortcuts. And that’s great. Because if you and I are going to get an ice cream and you spend the next 47 minutes trying every flavor.

Then, I’m going to say, “You know what, Brooke, it was very nice meeting you. I’m going to go home now.” Because you are not finding the heuristic that says, “Okay. I’ll have pistachios or something to balance it out. Let’s have tangerine. Thank you.” And you’re out the door. That’s good. That’s a good thing. Because it’s heuristic. You’re making a quick decision. And we all make quick decisions. So, I think we need to be helped in making good, quick decisions, rather than being educated or lectured to or trying to suppress our heuristics, and good luck with that.

But we just talked about that depletion. So, rather than doing all these unnatural deeds, we can just say, “I’m going to make a quick and dirty decision, help me make a good quick and dirty decision.” So, we see that we default, for example, with organ donation and organ donation, you can argue about whether or not it’s good. But the truth is, if everyone, almost everyone, signed up to be an organ donor, there would be more organs, not just for other people who want to take away my organs, God forbid if I die, but also God forbid if I need a kidney or anything. There would be more people out there giving it to me. That’s a good thing. 

So, if it’s the default, then more people will do that. And when I say people, I mean, all sorts of people including doctors, because doctors are also human. So, in England, the nudge unit, which is no longer called the nudge unit, it has a different name now. But what they did was they realized among other fantastic things that they did, that when patients are intubated, they might suffer from pneumonia. And a really good way of preventing that is through mouthwash.

Unbelievable, right? It’s such an easy fix. And doctors know that. They have been trained. It’s nothing new. But they’re human. So, they forget. They’re overwhelmed. And they’re overwhelmed with information and tasks. And if they forget, and you’re the patient and you catch pneumonia, that’s very, very unfortunate. So, what the nudge unit did, is it said, “Okay. Doctors like to think fast. They like to use system one or they’re just human and maybe they like to use system two, but sometimes it’s too much. Let’s give them an order form, where the mouthwash is already checked in.”

So, basically, we’re telling the doctor, you are giving this patient mouthwash. If the doctor doesn’t want to, they can cross it out. That’s fine. But what they saw is that before that default, before that nudge to put in mouthwash, 50% of patients received the mouthwash. And as I said, it’s crucial because the wants to develop pneumonia when intubated. After the nudge, it went up to 90%. That’s a major improvement with very little or no effort on the doctor side. And that’s brilliant. So, that was what the nudge unit did. And I think a lot of digital health developers and a lot of digital health applications are trying to do exactly that. 

The good ones will do exactly that. And sometimes they consult them, and I have such a good time doing that. It’s such a huge challenge. And when you crack it, it’s phenomenal. I mean, I’m sure that people just did the really ridiculously simple thing of just checking in mouthwash in the order form, they high-fived to one another, and they went for a beer because they’re British. And they always go to the pub for a beer and they deserve that beer. I would buy them the beer if I was there. They made a huge difference in many people’s lives with very little effort on the physician side.

Brooke Struck: So, I really like that you’re talking now about practical solutions that we can implement to help improve the circumstance. So, the example you just gave was a good one about the role that governments and regulators can play in trying to improve the decision environments of both doctors and patients. And you earlier talked about these three questions. So, whenever presented with a potential treatment option, the three questions are what are the risks associated with it? What are its potential benefits? And what are the alternatives? So, those seem like really valuable concrete questions that you can ask. And in terms of taking action to make this happen, you can write them down on a piece of paper and put a piece of paper in your pocket when you go to the doctor’s office, so that when your hands get sweaty when you’re about to get big news from your doctor and you put them into your pockets. You’ll find this piece of paper and remember you should ask, but what about doctors? Is there something concrete that they can do to help improve the decision environment when they’re working with patients?

Talya Miron-Shatz: I think doctors also benefit from thinking about alternatives. And I want to talk about it in the context of health inequities. So, you’re a white man. And if you and I both to get into the ER and let’s hope we never do, and you complain of pain, doctors are going to believe you because white men never complain. And if they report pain, then obviously I’m being ironic here, in case people don’t notice. So, if a white man complains of pain, give him pain medication for the love of God.

If a Black man complains of pain, are they really hurting? Or are they looking for opiates? That’s a scary one. That’s a scary study finding, likewise for Hispanic people, and likewise for another minority that I belong to, females. So, if a woman complains of pain, she’s probably being hysterical. She’s exaggerating. It’s psychological. I mean, she’s a woman. Let’s not forget that. And that is very frustrating. That is incredibly frustrating, I think. And we talked about doctors.

So, what can I do as a patient? I guess, not much. And the more I tried to do, the more hysterical I’m being considered. Great. I think as a doctor, you would be well served and you would be doing your patients a really good service by putting your confirmation bias aside, rather than saying, here’s a white man complaining of pain. Of course, he’s in pain. I’m not going to even think about maybe he’s not in that much pain. Try to think about, wait, this woman, this man who was non-white, just complained of pain, I think they’re exaggerating, could I be wrong?

That’s very potent. I don’t know if people have read, I hope they have, How Doctors Think by Jerome Groopman. And that’s a great book. That’s the first book that I read was like nonfiction in the medical domain. It’s mind-blowing. And it starts with a story of a woman who comes into the doctor’s office. She says she’s suffering from abdominal pains. For a long time, everybody thinks she’s anorexic. Everybody thinks she has psychiatric issues. She says, I eat pasta all the time. I can’t manage to gain weight. I have stomach aches all the time. And they just dismiss her as eating disorder, psychiatric whatever, only then do they realize that she is gluten intolerant. That’s why she’s having stomachaches. That’s why she can’t digest the pasta. It’s not through any psychological fault of hers. But until they put aside their assumptions, they can’t reach that conclusion. So, that’s the best advice I can give to clinicians is when you have the hypothesis, do me a favor, do your patients a favor and test another hypothesis as well, maybe that’s the wrong hypothesis. And that’s fine. But maybe it’s not. You could learn something.

Brooke Struck: In terms of the kinds of biases that you’re talking about around engaging with traditionally marginalized communities, one of our previous podcast guests, Lasana Harris, talked a bit about this. And one of the things that we discussed in that episode is also just exposure. That if you’re not in the habit of being in contact with people from a Black community, people from a Hispanic community, you treat the inputs that you get from them differently.

The research that he’s done is fascinating, and looking at how the brain responds to different kinds of interactions. And the neuro imaging that he’s doing in his lab is looking at how the brain responds, identify something that you cognize as a human, as opposed to identifying that thing as an object. And that it’s through exposure that we start to recognize that actually people who look different from us or speak differently from us or eat different foods. The more exposure we get to them, the more we realize we’re just people and the more we humanize them as opposed to dehumanizing them. 

So, if there’s something that we can add to the practical tools to take away from this, from doctors, it’s to actually engage with those communities so that when one member of that community is your patient, you don’t need to do as much system two work to overcome what your system one is pushing you towards. You can train your system one to a certain extent to respond more humanely to another human being by going and having contact with those communities.

Talya Miron-Shatz: Yeah. I would hope one responds humanely to human beings, regardless of profession and the other human’s origin. I think it’s a lot about stereotypes. And that’s just another mental shortcut. And it’s a good way to train ourselves to just say, what is this person telling? Not this Black person or white person, or female, or transgender, or whoever, they’re a person. And you have to learn that.

I don’t know if you used to watch 30 Rock. It’s a great show. Tracy Jordan tells Kenneth, he says, “You can’t leave. How will I tell White people apart?” And that’s obviously very racist. And it would sound terribly wrong if it was in the other direction. But you have to be able to tell White people or Black people, or Hispanic people, because everyone’s a person. And everyone has their pain tolerance and their way of describing their pain. And some people are more shy about it than others. And if they say, “Yeah. It hurts.” It could be a seven. It could be an eight. They would just never scream. It’s just not who they are. And we have to recognize that. We have to learn to identify the signals and to really know what is that person telling us, that specific person? And what is their specific language of describing their pain?

Brooke Struck: Talya, this has been really great. I think that there are a lot of valuable nuggets in here for patients, for doctors, hopefully for regulators as well thinking about how it is that we can create healthier decision environments, ultimately, to contribute to the goal of making healthier people. So, thank you very much for the insights that you’ve shared with us today and we hope to speak with you again soon.

Talya Miron-Shatz: My absolute pleasure. Thank you for inviting me.

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