Ramblings and gamblings. AKA: the post with a real footnote.

Ok. I know some of you in real life, and you're awfully smart. And some of you teach/think for a living, while the rest of you probably do so for free. So here's a plea for help.

I'm breaking my head over what I want to research.

This is not a trivial question. I'm a fellow; the whole point of re-entering indentured servitude for another three years is to have, at the end, the start of an academic career. A niche. Something I think about, and write about, and (ta da!) publish about that no one else does. So when I say: My Research, I mean: What I'm Going to Contribute to Greater Science.

Well, that's a bit self-important and capitalized, but I think you know what I mean.

So here's the problem. I know what I'm interested in. And I think it's something that no one in OB/GYN is writing/thinking about the same way I would. So - open road! But because of that, I also don't know where to start. I don't know the language that is used to discuss these subjects, and thus I am rendered inarticulate.

Which is to say: when I can't even search Google for it, I'm screwed.

So here goes: What I'm interested in is the emotional space that people occupy, and how that interacts with decisions about health care and medicine. To adapt from economics, I'm interested in how people - doctors, patients - maximize their emotional utility.

This all started with prospect theory, which is from the 1981 work of Kahnemann and Tversky. Basically, they worked with this phenomenally simple but profound finding: people respond differently to losses than gains.

I actually did an enormous Grand Rounds presentation on this (for those not in medicine, let's just say it was an unconventional presentation, and I feel lucky that it was relatively well-received.) I'm going to share some of it, just to better explain what I mean.

Example one:

Choose between:

A) A sure gain of $250 B) 25% chance to gain $1000.00, and 75% chance to gain nothing.

NOW:

Choose between

C) A sure loss of $750 D) 75% chance to lose $1000, and 25% chance to lose nothing.

Here's the way it works out when you actually conduct this experiment:

A)A sure gain of $250 (84%)

B) 25% chance to gain $1000.00, and 75% chance to gain nothing (16%)

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C) A sure loss of $750 (13%)

D) 75% chance to lose $1000, and 25% chance to lose nothing (87%)*

If you can do any sort of math, you know, even as you're answering these questions ,that mathematically answers A and C are equal risks, offering outcomes involving the same amount of probabilistic cash. And yet, it's really hard to answer C. Even though you found the outcome of that choice acceptable just a minute ago.

Here's a harder one:

Imagine that the US is preparing for the outbreak of a disease, which is expected to kill 600 people. Two alternative programs to combat the disease have been proposed. Assume that the consequences of the programs are as follows:

• If program A is adopted, 200 people will be saved

• If Program B is adopted, there is 1/3 probability that 600 people will be saved and 2/3 probability that no people will be saved.

Which program do you favor?

NOW:

Imagine that the US is preparing for the outbreak of a disease, which is expected to kill 600 people.Two alternative programs to combat the disease have been proposed. Assume that the consequences of the programs are as follows:

• If program C is adopted, 400 people will die.

• If Program D is adopted, there is 1/3 probability no one will die, and and 2/3 probability that 600 people will die.

Which program do you favor?

And the results:

•If program A is adopted, 200 people will be saved (72%)

• If Program B is adopted, there is 1/3 probability that 600 people will be saved and 2/3 probability that no people will be saved. (28%)

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• If Program C is adopted, 400 people will die. (22%)

• If Program D is adopted, there is 1/3 probability no one will die, and and 2/3 probability that 600 people will die. (78%)

I have found that it is actually painful for some people to answer this one; your heart races, and your palms get a little sweaty. It is an emotional burden to be asked to make this choice. And again, A and C are equal, B and D are equal. But the response to them is different.

The economic/psychology punch line here is that people are risk-averse for loss, but risk-taking for gain. That is, you'll tolerate a large amount of unknown and possible loss if you are in an emotional/cognitive space that's positively expressed; but you have almost no tolerance for possible loss if it's negatively expressed.

Crazy, right? I thought it was just - amazing. Powerful. And even as I realize how unsophisticated I am, and that this is probably stuff from Psych 101 that I, in my pre-med haze, seem to have missed, my mind was totally blown when I came across these ideas.

I researched them for my Grand Rounds presentation, and I found that there's TONS more of this stuff, all over the place, trying to delineate what people will, and will not tolerate.

But I think the main part of this phenomenon is one that I found to be largely left unsaid, and one that didn't have much research that tried to characterize it. That is, the emotion and the morality. There's some part of your character/soul/brain biochemistry that knows that crime by inaction is, in fact, not the same as crime by action (regardless of the fact that the outcomes may be identical). And that part of your character/soul/brain biochemistry that can tolerate A but not C, D but not B. Guilt, anxiety, empathy - all of those things that help us live in this world, and are apparently as real and as important to us as simple arithmetic.

I am supremely uninterested in whether this is character/soul/brain biochemistry, although that is of much interest in the social science and biology world. What I am interested is this emotion part. That the emotion is there, that is is so easily - but so predictably - manipulated, and that it can change everything about how you view a situation and about how you make the decisions you do is amazing to me. Because, I guess, I disagree with economists. I don't think people are making irrational decisions. I think they are maximizing other utilities, such as emotional utility.

Medicine in general and OB/GYN in particular is full of situations where this occurs: counselling gone awry (and how could it not, when even the construction of your sentence can make an option either appealing or intolerable?); health care interventions poorly received by the community; physician decision making. By gosh, it's everywhere!

I know I can't be the first person in medicine to think of looking at this stuff. I think, rather, that I'm uneducated and unsophisticated: it's such a huge field that I just got lost when I started look into it. (I got bogged down in a lot of social science literature, where I developed an aversion to doing surveys and asking people about their emotions and attitudes. I guess I feel that there must be a better way to figure out this out. Perhaps that's not true.)

So this is where you could help. What is that called, this maximization of emotional utility? (My husband, who is an economist, says it's not quite behavioral economics. Also, he objects to the blog name Bearded Economist, which is a shame, because that is what he is.**)

Does anyone know the terms for this field? How do you look this stuff up? How do people, in medicine, do research on this, if they do? Is this something that I can do research on and try to harness for good? Do I have to do surveys to do so?

Or do I really just want to be a novelist, and write terrible fiction about the emotional travails of distraught obstetricians?

Please advise.

*Tversky, Kahnemman. The Framing of Decisions and the Psychology of Choice. Science, Vol. 211. 30 January 1981.

**It's actually a goatee.