Hard Choices

Hard Choices

Anees B. Chagpar, MD, MPH

@AneesChagpar
Aug 06, 2014

I was thinking about hard choices recently…. You know, thoseones that really matter and for which there is no obvious “right” answer. I found this TED talk that I thought could provide an easy algorithm for finding the elusive optimal choice, but alas, itmerely told me that hard choices are hard because we, as individuals, have tobring to them our own values.

I thought about our patients who routinely face hard choices: Do I have a mastectomy, orbreast conservation therapy? Do I take chemotherapy, or hormonal therapy alone? Do I sign up for a clinical trial, or opt for standard therapy? For some, the answers may be obvious, butothers struggle to make these decisions. Perhaps even more telling is that, even for those for whom the answer is clear, there are plenty of people on either side of the dichotomousdecision. These decisions are personal, and they are affected by our values.

It’s no different in life…. I was mentoring a junior colleague, who had a similar dilemma – do I take job A or job B? Each had merit, albeit in different domains. For me, the choice was clear;but for her, weighing issues like uprooting her family and distance from friends were important considerations. What became clear is that we have different values, each personal toourselves.

My ultimate advice to her was to put values on her values. Harkening back to lectures I hadtaken at Yale’s School of Management, I told her to create an Excel spreadsheet…. (You can stop laughing now…. this really works!)…. and to list all of the factors that were important in making a decision – geography, salary, family issues, etc. -- ranking each of these with a weight. Then, evaluate each offer on those factors, do some simple math and voila! Tough decisions made simple.

If only all decisions were really that easy…. What becomes difficult is when the two choices truly are equivalent, and the math doesn’t lend itself to one choice or another. I wondered about patient decision support tools and whether this type of analysis would help, orwhether patients think about the eventualities of each path of a decision andmake a choice based on an instinctive response. Ultimately, it’s about maximizing utility – whether by quantitative analysis of factors, or simply going with your gut. We all face hard choices, and need to make decisions regardless of the uncertainty of what the future will truly hold. Perhaps the best news is that hard choices are often hard because there is no “right” answer, and no matter what choice we make, at least we are moving in a forward direction without being paralyzedby indecision.

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