Behavioral scientist Peter Ubel, M.D.

The Duke University professor explains his groundbreaking work, detailed in the text, Critical Decisions.

An internationally renowned writer and researcher, Peter Ubel is also a practicing physician, behavioral scientist and a marketing and public policy professor at Duke University. His work explores controversial issues about the role of values and preferences in healthcare decision making, and he's contributed to The New York Times and The New England Journal of Medicine, among other publications. He previously taught at the University of Michigan and has authored several books. In his new text, Critical Decisions, Ubel provides patients with tools to make confident decisions about their health and well-being.
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Tavis: Dr. Peter Ubel is a widely respected physician and behavioral scientist at Duke University and the author of three previous notable texts. His latest is called “Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.” Dr. Ubel, good to have you on this program.

Dr. Peter Ubel: Good to be here.

Tavis: Dr. Ubel’s very funny. He walks on the set and told me I wore a, Neil, he said I wore a UNC-color tie as opposed to a Duke-colored tie. I should have put a darker blue tie on. I apologize for that.

Ubel: You’re forgiven. (Laughter)

Tavis: To you and Coach K and all the good folk at Duke. I’m glad you’re here to talk about the text “Critical Decisions” because it seems to me that so often when doctors and patients get together, what they’re talking about, Dr. Ubel, are life-and-death decisions.

Talk to me about how honesty, how transparency, how openness enters the room in a setting like that when no doctor, I suspect, wants to concede that death is likely, because nobody wants to lose, and death so often is seen as losing.

So how do we get to a place in a doctor-patient relationship where honesty and transparency is central in the conversation?

Ubel: Actually, most of the times it is pretty honest and it’s transparent, but often in a foreign language.

Tavis: Okay.

Ubel: Where the physician is doing his or her best to explain what’s going on to a patient, but often the jargon that they’ve forgotten that you have to go to medical school to understand, often a little bit unaware of what’s going on inside their patients, like what emotions their patients are having, or whether they’re talking too fast or too slow.

So but I think honesty is pretty much the norm, with maybe the exception being when it’s such bad news that almost any human being would have a hard time giving it.

Tavis: There was a point in this country some years ago, as you well know, because you write about it in the book, where we had, at least we were told, that we were making a paradigm shift, a paradigmatic shift in the health profession where patients had more say.

A patient’s bill of rights, a patient’s right to X, Y and Z, and as I read the book, at least, you’ve argued that we have somehow failed in that transition.

Ubel: Yeah, I think we’ve begun a transition. We knocked doctors off their doctor-knows-all pedestal. We didn’t tell them where to stand.

Tavis: Right.

Ubel: We empowered patients but didn’t tell them what that meant, about whether they’re alone to make the decision or whether they work with their physician. So we started the revolution, but we haven’t completed it.

Tavis: Yeah. Your book is full of anecdotes. It’s full of personal stories, and one of the things – it’s always difficult. We do this “Road to Health” series because I think it’s necessary, I think it’s valuable to empower people with information that could help them live better lives, and health is such an important issue.

I say all the time – it’s not very smooth, but it’s true, that if you ain’t got your health, you ain’t got much of anything. So it’s worthy of a conversation, and yet part of the problem is that these books are so often written in ways that the average person can’t understand, they can’t follow.

So let’s go inside the text “Critical Decisions” and tell me what your decisions were about how to write this book in such a way that everyday people could embrace it and understand it.

Ubel: Oh, yeah, and a warning to your listeners, I’ve had at least one person tell me they missed a train stop reading the book, they got so absorbed.

Tavis: Oh, that’s a good endorsement.

Ubel: We humans learn – we didn’t have written language for a long time. We learned and passed on knowledge through stories, so that’s why there’s a lot of stories in the book. But overall there’s a story that tells – I try to tell how we got to where we are now and how we can go forward and do better in the future.

So I really start the story with 1975, when a woman was told that she had a lump in her breast and that she needed to have it removed, and she went to get the biopsy and when she woke up at the end of the surgery with not only the biopsy done but the breast removed, the surrounding muscle, the surrounding connective tissue – what’s called a radical mastectomy – even though the surgeon knew that a new study was going to come out that questioned whether we needed to be that aggressive with the surgery.

That woman was Betty Ford. Her husband, Gerald, was the president of the United States, but doctors knew best, and so he was telling the First Lady and her husband what to do. That was 1975, before we really had this revolution.

Tavis: You contrast that story of Betty Ford with the story of Catherine Williams?

Ubel: Yeah. Just 20 years later and I’ve got an emergency patient that’s come to the operating room and I’m not a surgeon, right? I was an on-call ethicist. The surgeon was there, another woman asleep with a cancer. But in this case, the surgeon was worried that he couldn’t go on with the surgery and be as aggressive as he needed to be without maybe involving her.

She had a throat cancer and they’d made a plan to remove the tumor and they thought they were on the same page, but when he got in there was more tumor than he thought there was going to be and he knew to remove the tumor would mean removing her ability to speak, and they’d never talked about that possibility.

So he said, “What should you do? What should I do?” What do you think he should do? I’m asking you. (Laughter)

Tavis: Oh. Communicate.

Ubel: So he could go in – so she’s asleep on the operating room table.

Tavis: Right.

Ubel: He could go in and take out the rest of that tumor because that had been the plan, but then she’d no longer be able to speak again. He could stop the surgery – that meant sending her back, letting her wake up, and then they talk about it and if they need to go finish the surgery they’d have to do it, like, a couple days later, which means a whole nother operation.

He was torn. So he asked me what I thought, and I said, “You need to wake her up. You can’t -”

Tavis: Yeah, communicate, that’s what I said, yeah.

Ubel: Yeah, you’re right, you did. Yeah, you have –

Tavis: I said, I said – did I pass the test?

Ubel: (Laughter) You passed it.

Tavis: I said “Communicate.” You looked at me like I was (unintelligible). I’m like –

Ubel: Yeah, sorry, sorry, yeah, you passed. (Laughter)

Tavis: Okay, thank you.

Ubel: It was the tie that threw me off. I needed a better answer.

Tavis: All right, okay, all right. Do you think, though, that is the norm, or was that an exception to the rule?

Ubel: Well, I think it was a sign of the change in times to 20 years later; we had doctors much more aware that some decisions aren’t just medical decisions. They depend on value judgments and the patient’s values matter. So that’s what it’s a paradigm, an example of, but it’s not the norm. The norm is that we’re struggling as doctors and patients, and I’ve been on both sides of the stethoscope, trying to figure out how to work together to make difficult decisions, and that’s something where – that’s what I’m trying to help us do better.

Tavis: Is it the case that the patient is always right? There’s this old adage in business that the customer is always right.

Ubel: Yeah, yeah.

Tavis: I get what we mean when we say that.

Ubel: Yeah.

Tavis: That’s not always true. The customer isn’t always right, but I get and you get it. So I ask is the patient always right? After all, it’s my body.

Ubel: Yeah.

Tavis: Am I always right if I say – if this is what I want, am I always right?

Ubel: No.

Tavis: Yeah.

Ubel: No. So a part of it is that my job as a physician is to understand is what you’re telling me reflects some deep, consistent values, that’s great, I need to know that. But there might be that misinformation is – maybe you’ve decided oh, I don’t want to have that procedure done because I hate surgeries and I’ll never feel good because you have to remove part of my leg or something.

Well, I happen to know a lot of patients have had this operation and they do great afterwards, and maybe we need to push back a little bit before you make a quick judgment about it, so.

Tavis: How much of this quagmire, this weightedness that the relationship between doctor and patient suffers under has to do with physicians, not all, but many physicians who are pushing procedures for a variety of reasons – because they’re sponsored by this particular medicine or they’re using this particular equipment or whatever, what have you.

But I can think of a couple of times in my own life, without calling any names, nobody should be scared, but a couple of times in my own life where even with my own doctors I’ve gone to get second opinions. At one point I was going in for a particular surgery and decided, “You know what? I’m going to pass on that.”

My doctor recommended it, the date of the surgery was set, things were ready to rock and roll, and I just decided that I’m not going to do that, and I’m glad in retrospect that I didn’t. It took a while for the thing to heal, but over time it finally worked itself out.

But I didn’t want to get – it’s my foot. I didn’t want to get my foot cut on and all that kind of stuff. So I ask how much of the duress in this relationship between doctor and patient has to be with doctors being pushed to do X, Y and Z for whatever extraneous factor?

Ubel: I think that doctors believe in what they do, so if you were, say, have localized prostate cancer, so a slow-growing cancer that’s just in the prostate gland, that’s a gland in a man, and you might get surgery to treat that, or you might get radiation.

If you go to a surgeon, they’ll probably recommend surgery as the best option. If you go to a radiation doctor, they’ll recommend radiation. I don’t think it’s just because they want to enrich themselves or because they have some terrible conflict of interest with some company.

I think you know what you see and you do what you believe in, and they spend their day curing people with these treatments and they can’t imagine any other treatment is better.

Tavis: Talk to me about – I don’t recall, having gone through this, I don’t recall you talking specifically about this, but it’s always, as a person of color, it’s important to me, and that is the breakdown that I’ve seen so many times between doctor and patient over a lack of cultural competence.

Ubel: Yeah.

Tavis: Just not trained how to communicate, how to handle, how to navigate the relationship with patients from different communities, different norms, different values, different understandings. It’s a real issue.

Ubel: Yeah, it is, and I think the more that you feel you can relate to your physician, the better off you’re going to be. There can be cultural barriers and age barriers and things.

Early in my training – so I’m 50 years old right now. Early in my training as I was starting medical school, I was 27 years old, I looked really, really young back then, okay? And I was taking care of a 55-year-old guy and at one point on this day he said, “Yeah, well, people our age,” to me, and I was like, a young-looking 27?

So at first I was like, what’s going on here? Then I realized what he’s saying is he related to me. I took it as probably the greatest compliment I’ve had in my career. I think we can overcome barriers with good communicate to where we don’t feel those differences.

Tavis: Yeah. So rate for me on a scale of one to 10, if you will, how you think we’re making progress in this all-important relationship.

Ubel: I think we went very rapidly in the mid-’70s from zero to six or seven, and I think we’ve kind of gotten hung up there. We’ve been inching along a little bit. We have a little better education in med school to help doctors communicate better. There’s things called decision aids that patients can look at to inform themselves.

That got us from six up to seven, seven and a half, but we’re not that last bit of the way.

Tavis: So what’s holding us back? Why are we stuck where we are?

Ubel: I think partly that we have to prepare patients to be prepared, and so I think part of why I tell a lot of stories in this book is to help people visualize what might happen to them and recognize it, and then go, you’re talking to the doctor and they get confused, and they go, “Oh, I remember that. You can get confused and the doctor doesn’t realize it. This is my time to step in and say, ‘Excuse me, slow down. Can you explain that again?'”

So it’s getting people ready for when they have those critical decisions to make. That’s step one. The other thing is I think we need to retrain physicians. I’ve put in ideas on that. That’s not as relevant to most of the readers, but yeah, we need to continue to improve medical education.

Tavis: Actually, it’s relevant to me, so let me ask about it.

Ubel: Yeah.

Tavis: If we were – because I just asked a question about cultural competence, for example, that that’s a real issue. So if we were, in fact, to retrain physicians, what two or three ways, two or three issues, do you think we ought to start with?

Ubel: Number one, I actually think that as part of medical licensure, if you’re the type of physician that interacts with patients, so maybe a radiologist might not always be a pathologist, right? I think seeing a videotape of yourself having conversations with patients and then critiquing them.

I think you learn so much by just stepping back and watching yourself interact. That would be a great step. In fact, there’s research showing that doctors dramatically improve behavior with pretty short interventions if they can hear or see themselves and the mistakes they’re making.

Tavis: How much of this is about patients becoming their own best advocates?

Ubel: That’s a huge thing. The right choice is not a medical thing. I need to bring medical facts to the table, but ultimately it might be a trade-off between length of life or quality of life, or between one kind of side effect and another.

If I don’t know what you care about, it’s like a waiter giving you a recommendation without finding out whether you’re a vegan. I’ve got to know what you care about to be able to give you a good recommendation.

Tavis: What advice with regard to patients becoming their best advocates – it’s one thing to retrain doctors, but I also heard your other point. We have to prepare patients to be prepared. So talk to me about how a patient feels empowered to walk into his or her doctor’s office and to have the kind of conversation that needs to be had.

Ubel: One size does not fit all, right?

Tavis: Dysphoria.

Ubel: So I think sometimes it means bring in an advocate, because maybe you’ve known your doctor for a long time and you feel awkward bringing up a difficult subject because you don’t want it to affect the relationship. Maybe your spouse isn’t so shy. Maybe he or she will jump right in there and advocate for you.

Maybe your kid is the person who’s going to stand up and help out. So that’s one thing, is bring someone in. Another is I think arm yourself with information before you get to the encounter, so that you’re just up to speed as much as you can on what’s going on with your own health.

Own your health, own the knowledge about your body, and then you’re ready to join in more easily.

Tavis: Yeah. It may be one of the answers you just offered now, but where do you find that patients are most lacking when it comes to information about their own health?

Ubel: Boy, that’s a good question. It varies so much. Some people come in and they are practically encyclopedic, but they’re not in touch with their own emotions about what’s going on, and emotions play a huge role in all decisions you make in life. But medical decisions often carry a lot of emotions.

So I’ve had these patients who are incredibly well informed and they’re afraid of needles and they don’t want to try something because of a needle. I say, “Well, can you try the needle just once or twice and see how much it bothers you?” “Oh, no.” So it’s real different from one person to another.

Tavis: I’m glad you went there, because it raises, to me at least, a fascinating question about how much, again, of this, the strain of this relationship has to do with patients being emotional, and I want to be sensitive in asking that, because if ever where was something to be emotional about, it’s about your health, particularly if we’re talking about a life-and-death issue.

But from the physician’s side of the coin, how frustrating is it to deal with doctors who are – I don’t want to say overly emotional, again, because it’s your health here, but are extremely emotional?

Ubel: I think that the bigger challenge, and it can be very hard if people – and I think there are times where you just realize you have to have a very short – much less information in that conversation and let the emotions come down and come back another day and try again, right? But I think the bigger problem is that sometimes we physicians have been there, done that so often we forget what it feels like to the patient.

We say, “Oh, you’ve got a very small, localized cancer,” and to us that just means no worries, no big deal, but to you it’s cancer, and probably every other word I said was blah, blah, blah, cancer, all right?

So we forget that. So I think one of the things is to try to – I think as a patient, don’t just assume your doctor knows what you’re thinking and feeling. You just can’t.

Tavis: This is not, again, something not covered in your text, but it’s a personal axe of mine to grind, and I grind this axe in part of my own interest, but in fairness because I happen to be a personality. When I go to the doctor’s office, typically I can go in a back door, a side door, and they usher me into a VIP area and they get to me relatively quickly. Now, that’s not always the case because sometimes –

Ubel: You’ve just most of your audience now dislikes you that much (unintelligible).

Tavis: Yeah, no, no, no, no, I know. But that’s not always the case, to your point, because sometimes I’ll be sent by my doctor to see – I have in my career been sent, my life, been sent by a doctor to see a specialist, and I get to the specialist, they don’t know me from Adam. So I get treated like everybody else because it’s not my personal physician. You see where I’m going with this.

I found myself sitting in waiting rooms and running through the rat race, and again, it’s not something you necessarily cover directly in the text, but I wonder how much of this relationship has to do with patients being made to feel like they are just another number.

Like they’re on a rat race. You go to the doctor’s office, you have an appointment. If I get to your freaking office on time, don’t make me sit for an hour and a half to two hours, or don’t rush me through when you get me in there, or – I could do this all day long. I don’t need to explain this to you.

But I’m trying to figure out in any other relationship you want to feel like you’re respected. You want to feel like you matter. So many Americans listening right now, I’m sure, or watching right now know exactly what I’m – yeah, I heard them. I heard them say they agree with me, that they understand this. So how much of that impacts the relationship?

Ubel: Yeah, it’s inexcusable. I’m embarrassed for my profession that we do this still.

Tavis: You guys are the worst at this. Doctors are the worst. You sit in doctors’ offices longer than anywhere, and then you get overcharged – again, I’m grinding my axe. But you sit too long, you get overcharged, you get – it’s horrible.

Ubel: I’ll tell you there are – I really worked hard to try to stay on schedule, and if you know that every day by 11:30 in the morning you’re an hour late, you should adjust your schedules accordingly, right? There are days where I was late, and that’s because someone had a really big problem and I had to take them down to the emergency room where I was or something, right?

I worked in the VA system. I would come to those next patients and the very first thing I would do is apologize profusely and just say I’m really sorry you’re late, I couldn’t avoid it. I want you to know if you ever get that sick when you’re seeing me I’ll take the time I needed to take care of you too.

But not everybody does that, and some, they just feel like all it matters is that I, the doctor, run on time, not you, and that’s a bad thing. Mention it to your doctor. If you don’t get a good response from your doctor, might be time to find another one.

Tavis: Yeah. I wouldn’t raise this but for the fact that you raised it, so I’m going to follow you in.

Ubel: Uh-huh.

Tavis: You mentioned that you at one point worked in the VA system.

Ubel: Yeah.

Tavis: Give me your sense of how you think we do as a nation treating those who have served and put their lives on the line.

Ubel: Sure, yeah.

Tavis: There’s a great debate always about that particular system.

Ubel: Yup.

Tavis: And how we treat, particularly these days, how we treat these soldiers, men and women, when they’re coming home. So since you went there, tell me about how you think we’re doing in the VA system.

Ubel: Sure. Now, what you read about in the news, there’s occasionally certain VA hospitals that are really having bad problems. You also read now with a lot of the veterans coming back that we’re having to ramp up mental health services and we’re not doing it fast enough, and that’s, we’ve got to take care of the people who serve our country.

What I can tell you from my experience, though, practicing more than 15 years in the VA, I’m proud of the care we give to veterans, that many studies have compared the quality of medical care in the VA system to other parts of the country, and it either does as well or does better than where a lot of people are getting their medical care.

We had an electronic medical record system that worked well many years before anybody else, and that allows us to coordinate care and not order too many tests, to know what the other doctor thought, to make sure when I order a medication, if it conflicts with another medicine you’re on, I get a warning right there from the computer. So I think on average, outstanding care in the VA.

Tavis: Again, since you raised it, how is the issue of digital records and the concern and fear that many patients have going to impact the decisions and the relationships patients have with their doctors.

Ubel: Yeah, I think sometimes now when you’re seeing a doctor you’re not talking like this, you’re talking like this, and the doctor’s out there typing and looking at the computer. That’s not good, all right? So I think the good physicians, they take that computer monitor, they turn it over, and they say, well, look, now, look how your blood pressure’s been going up, and you can graph these out on some of these programs.

It’s a great learning too, great communication tool. Then you know what, they can type up their note outside the room and fine. So I think it can be a real way to improve communication if used correctly.

Tavis: Our population, as you well know, being a physician, is aging. How does the aging population affect the issues raised in this text? What’s the relationship between the two?

Ubel: Yeah, yeah, no, so some people say this is just a generational thing, right?

Tavis: Right.

Ubel: Older people, they just defer to their doctors, and young people, they really – that’s partly true, but it’s amazing when you get a sudden illness how quickly you start acting like you’re (unintelligible) person in that all of a sudden you’re so scared you’re like, “Tell me what to do, Doctor.”

I even had not a major illness, but I had a bulging disc in my back. I was training at the Mayo Clinic at the time. I would read about every medical problem and all my patients to make sure they got the right treatments. When I had my own back problem I didn’t go to the library once. I just went to the surgeon and said, “What do you think I should do?”

So it’s amazing, we all can act like the different generation once it’s your body on the line.

Tavis: Yeah. This debate that we’ve had recently about healthcare and –

Ubel: The politics debate?

Tavis: The politics, yeah.

Ubel: Oh, one of my favorite topics.

Tavis: Exactly. And if Mr. Romney were to win they want to do what they can to overturn Obamacare, whatever that means. The Supreme Court obviously has had its say on a certain aspect of this. But does that in any way scare you, concern you, impact the issues raised in the text?

Ubel: Big, complicated topic. I’ll say this – no matter who’s elected in November and then is president in January, what’s going to happen no matter what is people are going to have more of what they call skin in the game. The way our healthcare system is evolving, we’re paying more out-of-pocket for our healthcare than we ever has as patients.

Co-pays are higher and insurance kind of runs out earlier. So you’ve got to get that much more involved in your own decision, and when your doctor wants to prescribe something really expensive, try to learn how to say is there an alternative, because that’s really costing me a lot of money, Doctor.

So I do think no matter what, these issues are even more relevant.

Tavis: Impolitic question to close on, but I want to ask anyway. There’s a reason why they call it the practice of medicine, so that even with consultation and conversation, sometimes the right decision is not made because doctors are not perfect. You are not perfect as human beings.

Again, that’s why they call it the practice of medicine. So what do you say to patients when the right decision was not made?

Ubel: You can’t live your life in reverse. You just have to go forward with what the next decision is or how to get on with your life. Living with regret, I don’t see the point of it. If you realize that it was a bad decision you made with your doctor and you have other decisions coming up with that same one, you might want to change physicians, or at least let them know why you’re upset with what happened.

Tavis: The book is called “Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together,” written by Dr. Peter A. Ubel. Dr. Ubel, good to have you on the program and thanks for your insights.

Ubel: Thanks a lot. Nice to talk to you.

Tavis: My delight to have you. That’s our show for tonight. You can download our app in the iTunes app store. We’ll see you back here next time on PBS. Until then, good night from Los Angeles, thanks for watching, and as always, keep the faith.

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Last modified: June 30, 2013 at 9:42 pm