Straight Talk about Disease Prevention

When physicians say that the best part of being a doctor is talking to patients, I think of my father's internal medicine practice in Palo Alto, California. From 1935 to 1972, he practiced just the way he wanted to. New patients got an hour. Return patients got a half hour. Before Medicare, having an expensive test meant money out of pocket. Ten minutes of talk often led to a prescription for empirical antacids instead of an upper GI series. The talk was pleasurable, it was an exercise of clinical skill, and it made a difference.

Despite the central role of talk in office practice, it hasn't been part of the medical curriculum until recently. During medical school and residency in the 1960s, no one watched me interview a patient or actively taught me how to direct a conversation or counsel someone. Talking with patients has higher curricular priority now. Most medical schools give instruction in patient interviewing. Observing the student during an interview is common practice. Ironically, teaching interview skills has improved as the time for talk has shrunk.

What evidence should be covered in a medical school lecture about talking to patients? The speaker would find relatively slim pickings for an evidence-based lecture. One topic would be the heuristics that people use to make decisions. A heuristic is a method—a shortcut—for performing a cognitive task, such as estimating a probability (1, 2). Framing, another well-researched topic (3), is the subject of this editorial, which explores Halvorsen and colleagues' article in this issue (4).

Tversky and Kahneman (3) described framing effects in a seminal article in 1981. To illustrate the basic idea, we'll consider an example in which people choose differently between a sure thing and a gamble depending on how the outcome is worded. If the …