When the unknown is not so bad

Despite a host of medicines, the man continued to suffer. His severe ulcerative colitis, an inflammatory condition of the large intestine, caused bloody diarrhea and crampy abdominal pain, and he rarely slept through the night without having to wake up to race to the bathroom.

Realizing that his medicines weren’t up to the task, I spoke with him about another treatment option. I told him that if he had his colon removed, the surgical procedure would cure him of his ulcerative colitis but would leave him, at least temporarily, with a colostomy.

Horrified at the thought, he said he’d rather stick with the devil he knew, predicting that life with a colostomy would be worse than life with ulcerative colitis.

But was he correct? Research has shown that people often mispredict the emotional consequences of unfamiliar circumstances.

Junior faculty members, for instance, predict that they will be miserable if they fail to receive tenure, but studies find no discernible difference in the happiness of faculty members one year after either receiving tenure or being denied tenure.

Similarly, people who play the lottery predict that they will live in a perpetual state of glee if they win, but studies have found that winners soon return to their normal level of happiness.

And those who are healthy mispredict the emotional consequences of chronic illness and disability, imagining that paraplegia or emphysema or kidney failure would make them miserable when, instead, most people with these conditions report being quite happy.

Experts in medical decision-making, like me, are very concerned about such mispredictions, because good decisions about health often depend upon accurate predictions.

In fact, people often make bad decisions because they make inaccurate predictions. They choose to go to mindless action movies, even when more intelligent films will bring greater edification and longer-lasting pleasure. They tape humorous posters up in their college dorm room walls even though research has shown that they’d be happier with more tasteful decor.

My patient with ulcerative colitis faced a much more serious decision than choosing a movie or a dorm room poster. But in making that decision, he was just as dependent on accurate predictions as filmgoers and college students decorating their dorms.

In deciding whether to have his diseased colon removed, he needed to imagine what life with a colostomy would be like.

Recently, my research team at the University of Michigan discovered that patients with colostomies report experiencing positive moods the majority of their waking hours. We also discovered that when healthy people imagine life with a colostomy, they envision experiencing bad moods the majority of the time, just like my patient had imagined.

At the time I cared for this man -- several years ago -- I could not draw upon my research findings to inform his decision. So I did the next best thing, I asked him to collect his own data. I urged him to speak with patients whom he met in the gastroenterology clinic to see what life with a colostomy is really like.

To a person, they told him that having a colostomy wasn’t as bad as they thought, and was far better than living with the symptoms of ulcerative colitis. But he continued to resist the operation, despite the results of his data collection: “They told me they were happy,” he said to me, “but I simply can’t believe it.”

As a clinician, I work hard to educate people about how their illnesses will affect their lives, so that they can make informed decisions regarding their healthcare. In this gentleman’s case, I expected that such information would show him that surgery would improve his quality of life. I was wrong. In the time I cared for him, he never opted for a colostomy, choosing instead to suffer regular severe abdominal pain and nights of interrupted sleep.

I had been sure, after he looked into the matter and could make an informed decision, that he would take my advice and have the colostomy. It looks like I, too, am susceptible to mispredictions.

Peter Ubel is an internist at the University of Michigan and the author of the book “You’re Stronger Than You Think: Tapping Into the Secrets of Emotionally Resilient People” (McGraw-Hill, 2006).