Humans have a tendency to overestimate our abilities and those of people we trust. It’s been called the Lake Wobegon effect, after a mythical place where “where all the women are strong, all the men are good looking, and all the children are above average.”
It’s a punchline with a dark edge. Consider the following:
According to analysis by the Pew Research Center, women earned 84 cents for every $1 made by men in 2012. Here’s the quote that grabbed my attention:
“While there is a general perception, especially among women, that men have an unfair advantage when it comes to wages and hiring, relatively few working adults report these types of gender biases at their own workplace.”
That is, women believe that discrimination happens, but don’t perceive it happening to themselves.
Here’s another quote that gave me pause, from a This American Life episode about black and white actors hired to try to rent the same apartments, to test if there is a practice of racial discrimination in certain locations. One woman, who is black, was turned away from an apartment building by a super who seemed, to her, to be perfectly affable, but who, in fact, had discriminated against her:
“It wasn’t that she couldn’t believe someone might have discriminated against her in enlightened New York City, but she thought of herself as very good at reading people, how they were responding to her, and she had detected nothing.”
My fieldwork notes are filled with stories about people who believed that their local or primary doctor was enough of an expert to guide them through a rare disease or complicated procedure. Until they found out that the clinician had missed a major clue or did not tell them about a certain drug or failed to refer them to a specialized treatment center. Before that moment, they had detected nothing, no reason to worry.
How did they find out? By connecting with other people with the same conditions online who, having been through it before, could tell them the truth about what they faced — and what they should do next.
Big piles of survey evidence over the years confirm your position, Suzannah. Everyone LOVES “their” doc/clinic/hospital, while in the next breath opining that health care generally is going to hell in a handbasket
I need to find that research — if you have a link or two handy, please share!
Here’s one potential source of references to address the first part of the claim:
Rama K. Jayanti and Thomas W. Whipple. Like me … Like Me Not: The Role of Physician Likability on Service Evaluations [PDF]. Journal of Marketing Theory and Practice, vol, 16, no. 1 {winter 2008), pp. 79—86
Thanks, Joe!
Michael Millenson’s sharp eye saw a parallel between this post and one written by Carolyn Thomas, aka @HeartSisters:
When doctors can’t say “I don’t know”
As he put it (on Twitter, so briefly): “Sometimes wrong, but never in doubt”: replaces “First, Do No Harm”?
Again, how do people guard against this?
Hello Susannah and Happy New Year to you! Thanks so much for including a link here to my Heart Sisters post. I love Michael’s Twitter quote, although it is a wee bit cringe-worthy, isn’t it?
How do we guard against this “Sometimes wrong, but never in doubt” phenomenon? That’s such a good question.
When a physician tells a (sick) patient something, anything, in a confident, self-assured manner, it takes a very special (and non-sick) person to raise a cautious hand and question that kind of assuredness. After all, docs are the ones with the letters M.D. after their names, a reality in the relationship hierarchy that can automatically put the patient in an immediate status imbalance.
I like Dr. Jerome Groopman’s recommended list of three questions that patients could ask their doctors when discussing a serious diagnosis:
1. Is there anything else this could be?
2. Is there anything that doesn’t fit?
3. Is it possible that I have more than one problem?
regards,
C.
Acknowledging the general prevalence of gender bias while not recognizing gender bias in one’s own workplace reminds me of the way people sometimes bemoan the corruption of politicians while holding their own elected representatives in relatively high esteem. I’m not sure I’d equate this with the Lake Wobegon effect, but it does seem to have some commonalities: superiority bias mixed with ingroup bias, and perhaps some normalcy bias (“it could never happen to me”).
Although the 60s ushered in an era where the people (and the press) became more willing to question authority, medicine seems to be an area where authority remains relatively unchallenged among the general population (though you and I both know many exceptions to this rule).
I believe effort is a important factor.
I wonder if there are significant differences between the amount of research people do about a disease or condition and the amount of research people do about other important areas of their lives. For example, how many people simply accept whatever a trusted stock broker tells them about a “good investment”, or what a trusted car dealer tells them about a car that is “just right” for them, without doing additional “external” research?
I’m reminded of Barry Schwartz’ book, The Paradox of Choice, in which he cited numerous studies that show people become overwhelmed when faced with too many options. He has a section in chapter 2 entitled “Choosing Medical Care” in which he cites a 1999 New Yorker article by Atul Gawande, Whose Body Is It Anyway?, which cites earlier studies showing that “patients commonly prefer to have others make their decisions for them”.
Schwartz notes that while the “blessing” of making medical decisions is increasingly bestowed on patients (primarily women), the proliferation of treatment possibilities – increasingly including nontraditional practices – can be a significant burden.
One common theme I’ve detected among many e-patients, who are willing to consult external resources (beyond their own doctors), is persistence and perseverance. Amid the successes and failures in their searches for solutions, they all get an “A” for effort.
Thanks, Joe – great idea to bring in the Paradox of Choice and the paralysis people seem to especially feel in the face of a health care choice. The question is: Can it change? Can people become aware of it before a crisis hits and then ask the questions that Carolyn lists? Or can they at least throw out a lifeline to a trusted friend, caregiver, or patient navigator to help ask those questions for them? Is this one of the ideas behind concierge practices — an expert appointed to your case, through thick and thin? Note: I don’t know. I’m asking 🙂
Absolutely. I’m pretty sure there was something about this in Thinking, Fast and Slow, but it’s not coming to mind.
I’ve noticed what seems to be a related effect, a response people seem to have when they realize they’re under (medical) threat: time after time I’ve seen people, when they discover they’re in big trouble, instantly become absolutely certain they’re in the best place they possibly could be, and “Boy am I lucky to be here.” In fact, the WORST time to awaken someone about the need for change is when they’re “under attack.”
The impulse seems just like when you realize you’re in a rocky rowboat – you don’t step out, you hunker down. So I think of it as the “hunker down reflex.”
It happened to me at my diagnosis. Happily in my case I was right. But that blinded me to things that were done wrong, including forgetting to remove my catheter (raising the risk of infection), losing an important specimen, leg surgery that failed and had to be done over, and on and on. (Later I learned that they lost my entire kidney, so I couldn’t contribute tissue to the Cancer Genome Atlas.)
Yet through all of it I was sure those things were inexplicable anomalies, and I kept thinking how glad I was to be at this excellent place.
A longtime friend, highly critical of the establishment in college, had an accident and was taking way too long to recover, but he was certain he was in the best place possible.
In my non-RCT impression, this “reflex” is so powerful that I’d wager there’s something at the base of the brain that drives this, so addressing it rationally won’t be useful – not unlike the Heath brother’s “elephant, rider and path” metaphor.
A related meme is in The Hitchhiker’s Guide to the Universe, in which the most invisible thing in the universe is an SEP – Somebody Else’s Problem.:-)
Thinking Fast and Slow is my lunchtime reading — one chapter a day, sometimes less if I have to stop and think and stare into space for a few minutes to let the ideas settle. I’ll keep my eyes peeled for the effect you describe.
As I wrote to Joe, I love that we are bringing in more evidence that this is real, but I would love even more to identify how we can help people avoid the bad outcomes of this known problem. I know that ACOR played a big role in waking you up to the possibility that you were receiving the right treatment, but maybe other mistakes/oversights were being made — were there other factors?
> I would love even more to identify how we can
> help people avoid the bad outcomes of this known problem.
Honest question: if as I suspect it’s an unconscious thing, can there be any other remedy than consciousness raising?
I don’t know if in Thinking you’ve gotten to Kahnemann’s thing about illusions … I blogged about it (with animation) as System 1, System 2, Elephants and Illusions. As I said in a comment there to David Morris, “I have to say, the depth and chewiness [of the book] is necessary, because its ultimate message is so irrational, and so unacceptable to the thinking mind, that only overwhelming evidence will be convincing.”
Having said that, though, for years I’ve been asking for a compelling popular film that leads people through a classic challenge story, in which our hero(ine) goes through some learning and gets transformed, so that then when the BIG challenge comes, s/he’s prepared and wins the day.
Perhaps the story for this case would be one where the hero(ine) discovers data about what’s really going on, distinct from the Matrix-like illusion.
Ah, I loved Thinking Fast and Slow, and I think Susannah’s practice of reading it slow[ly] is the best way to digest its insights.
I’m currently reading The Rational Animal, by Douglas Kenrick (evolutionary psychologist) & Vladas Griskevicius (behavioral economist), in which they deconstruct the human psyche into seven subselves. In describing the “self-protection self”, they report on an experiment that compared preferences and choices made after watching a scary movie vs. after watching a romantic movie. “People become especially receptive to messages about following the crowd [vs. standing out from the crowd] after watching a frightening movie clip”.
Along a similar trajectory, and related to your observation about people’s responses to medical threats, I recently heard an NPR story, Nothing Focuses The Mind Like The Ultimate Deadline: Death, which reviews the new Tikker wristwatch (which shows a countdown timer set for the date of your statistically expected death) in the context of terror management theory, in which humans tend to become more close-minded and more tenaciously cling to the familiar (and perceive the unfamiliar as threatening) in the face of our death.
“How did they find out? By connecting with other people with the same conditions online who, having been through it before, could tell them the truth about what they faced — and what they should do next.”
This is why, at Intel Health Day, in the 90’s, where I was invited to speak, thanks to Tom, I spoke of the peer-to-peer communities as a new form of peer reviewed publication. That remark, delivered to hundreds of doctors had over 1/2 of them leave the room instantly, fuming and screaming. They didn’t understand that maybe, just maybe, they had the wrong perspective, or as Tom said in 1977, “the wrong person has been holding the map“
Yes! Your post on the topic of maps is a must-read. Everyone, please check it out:
Error of Perspective and Map Issues: The Health Care Edition
Is there a way for someone (me) replying to self-remove/delete a post (i.e. my “test”)? Thank you, Susannah.
Hi Elin, I deleted your “test” comment but I’m leaving this one for two reasons:
1) Once I’ve approved one of your comments, you are a “known” commenter on my blog and, if you don’t include links, your future comments won’t need to be personally approved by me. Btw, I love when people include links! It just might take me a minute (or a half-day) to get to a place where I can approve those comments.
2) To let everyone know that my approval of comments is sometimes slow, esp. on weekends when I like to be outside, away from even my beloved smartphone. But I always get to them! So please keep posting.
Thank you!
Hi Susannah, thanks for encouraging me to post to your blog! A first for me, though I’ve been doing online health communications and community building for over two decades.
YES, *it* — people — can change. How? Through information, access and support among and between healthcare consumers/patients and health professionals alike. To help you along the path of exploration, I suggest the following:
— For gender/racial bias and awareness (or lack of it), check out Project Implicit: http://www.projectimplicit.net.
— To gain a better understanding of influence and persuasion — and how to increase awareness of factors that influence decision making — my go to guy is Robert Cialdini. Cialdini’s website is http://www.influenceatwork.com/robert-cialdini-phd/dr-robert-cialdini-phd/. And here’s a short, excellent YouTube video on the science of persuasion based on Cialidini’s research: http://www.youtube.com/watch?v=cFdCzN7RYbw.
— BJFogg and his work in persuasion and behavior modification, especially as they pertain to technology: http://www.bjfogg.com.
— Ken Pelletier, yet another expert who has researched and published extensively on health promotion and decision making. Though Ken has more recent publications, I think you’ll appreciate this 1994 piece from The Healthcare Forum Journal http://www.well.com/~bbear/pelletier.html. You can learn more about Ken here: http://integrativemedicine.arizona.edu/about/directors/pelletier
— And finally, no list of health promotion/behavior modification researchers/experts would be complete without Wendy Lynch. You can learn more about Wendy and her work in health care decision making at http://altarum.org/staff/wendy-lynch and http://lynchconsultingltd.com/.
As I have more thoughts and think of more resources, I’ll be happy to post them.Thanks again for your encouragement. I am an admirer or your work and efforts.
Thank you, Elin! I’m honored to host your first blog comment — and I’m looking forward to digging into these resources.
Susannah, speaking of Wendy Lynch, this extensive research was released this morning by Altarum. Topics include:
“Has a doctor ever given you more than one option of treatment or medication and invited you to discuss the alternatives and choose among them?”
“Information sources used to select a doctor”
“Online Access to Personal Health Information and Providers”
For methodology and answers, go to:
http://altarum.org/sites/default/files/uploaded-related-files/Altarum%20Fall%202013%20Survey%20of%20Consumer%20Opinions.pdf
Thanks, Elin!
It’s an intriguing study — note the low % of respondents who use fitness trackers/wearables or health apps, for example. But it’s also worth noting the methodology — paid panelists not representative of the national population, but rather a narrower definition of “health care consumers.” The researchers are clear about it, but anyone citing the study needs to include that caveat.
Excellent observations, thank you. I want to ask Wendy, too, about the higher percentage of female respondents. My guess is they surveyed more women than men since women are the primary decision makers about health matters for their family members. Wendy and I worked together decades ago, by the way, when I was publisher of the nation’s leading medical self-care newsletter and the medical self-care program, Taking Care.
Today’s example of a possible Lake Wobegone effect in health care and its insidious results:
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality
(JAMA Internal Medicine 2012;172(5):405-411.)
http://archinte.jamanetwork.com/article.aspx?articleid=1108766
Key quotes:
“Patient satisfaction is a widely used health care quality metric. However, the relationship between patient satisfaction and health care utilization, expenditures, and outcomes remains ill defined.”
And (emphasis added):
“In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.
While most health care quality metrics assess care processes and health outcomes, patient experience or satisfaction is considered a complementary measure of health care quality. Patient satisfaction data may empower consumers to compare health plans and physicians, and both the Centers for Medicare & Medicaid Services and the National Committee on Quality Assurance require participating health plans to publicly report patient satisfaction data. Health plans use patient satisfaction surveys to evaluate physicians and to determine incentive compensation, and consumer-oriented Web sites often report patient satisfaction ratings as the sole physician comparator.
Satisfied patients are more adherent to physician recommendations and more loyal to physicians, but research suggests a tenuous link between patient satisfaction and health care quality and outcomes. Among a vulnerable older population, patient satisfaction had no association with the technical quality of geriatric care, and evidence suggests that satisfaction has little or no correlation with Health Plan Employer Data and Information Set quality metrics.
In addition, patients often request discretionary services that are of little or no medical benefit, and physicians frequently accede to these requests, which is associated with higher patient satisfaction. Physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services, such as advanced imaging for acute low back pain.
Although benefits of discretionary care are by definition limited or absent, discretionary services may lead to iatrogenic harm via overtreatment, labeling, or other causal pathways. In a national Medicare sample, health care intensity varied widely among patients across US regions, despite similar illness burdens. Within 3 chronic illness cohorts, greater health care intensity was associated with increased patient satisfaction with some aspects of care but also with higher mortality and without improvement in the quality of care. Discretionary care has been similarly associated with added risks and costs in other studies.”