Medical Minimizer or Medical Maximizer: which one are you?

~ Carolyn Thomas

by Carolyn Thomas   ♥   @HeartSisters

I’ve been thinking lately about why so many heart patients don’t seem to follow their doctor’s advice (because that’s the specific topic I was invited to speak on during the annual Canadian Women’s Heart Health Summit being held in beautiful Vancouver, BC).

I’m pretty sure I was invited to speak because I’ve been harping on about the patronizing term “non-compliant” for years.  This is how some physicians label patients who are not advice-followers. I’m not a physician, so I tend to rely on what others far above my pay grade offer as suggestions to replace that cringe-worthy term. See also: First, There was Compliance. Then, Adherence. Now, Concordance.

No matter what you call it, researchers tell us that there are several commonly reported reasons that many patients don’t follow ‘doctor’s orders’. This week, I learned about another reason:         .

First, let’s review popular suggestions on how to help patients become more “compliant”:
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♥  Physicians generally believe that what patients need is MORE INFORMATION!

♥  The Silicon Valley hipsters I met at Stanford University generally believe that what patients need is MORE TECH! (e.g. BEEPING FLASHING DIGITAL PILL BOXES!)

♥  The Quantified Self movement (motto: ““Self-Knowledge through Self-Tracking”) generally believes that what patients need are WEARABLE TRACKERS that track every trackable health indicator from bowel movements to how many times they roll over in bed each night.

I like the wise theory expressed by Boston cardiologist Dr. Lisa Rosenbaum in The New England Journal of Medicine:

“I wanted to believe that if my patients knew what I know, they’d take their medications. But what I’ve learned is that if I felt the way they feel, I’d understand why they don’t.”

This is why I’m focusing my conference presentation not on the more frequently reported reasons for ignoring a doctor’s advice (like the high cost of drugs, complicated dosing schedules or distressing side effects) but on the “feeling” reasons that Dr. Rosenbaum prefers.

Here’s a reason I’d never thought about before:  this past week I read an essay by electrophysiologist Dr. John Mandrola (a cardiologist who specializes in heart rhythm problems) in which he mentioned how the personality styles of patients can also influence their health care decisions – specifically Medical Minimizers vs. Medical Maximizers.  For example:

“A patient who is a Medical Minimizer would look at a 25% estimated reduction in the risk of a future cardiac event and think that’s not worth taking a pill every day, while a patient who is a Medical Maximizer would want to do everything possible to reduce the risk of a cardiac event – and take that pill.”

There’s even something called the official Medical Maximizer-Minimizer Scale (1) or MMS  – to figure out which one you are. (I’m kidding, of course. You probably already  know which one you are. But the question remains: Does your doctor know?)

In their 2012 book, Your Medical Mind,  Drs. Jerome Groopman and Pamela Harzband wrote that “each of us has a medical mind, a highly individual approach to weighing the risks and benefits of treatments. Are you a minimalist or a maximalist, a believer or a doubter, do you look for natural healing or the latest technology?”

According to researchers, people who score highly as Medical Maximizers on the MMS scale (i.e. those with a preference for MORE medical interventions compared to people with a preferences for LESS) have been shown to:

  • use more prescription medications and visit a physician more frequently
  • be more likely to get imaging tests, blood draws and vaccinations
  • report more overnight hospital stays in the past 10 years compared with people with a preferences for less care

Medical Minimizers prefer far less medical intervention, by comparison, but don’t necessarily refuse doctors’ suggestions at all times. They may be willing to accept recommended testing or treatment options, but only if they’re fully convinced of the necessity.

Is it better to be a Medical Minimizer or a Medical Maximizer?

Here’s how Dr. Laura Scherer, a researcher and associate professor at the University of Missouri-Columbia responds to that question:

“Your preference for maximizing or minimizing can be either beneficial or not, depending on the situation.

“The drawback of being a Minimizer is that you might delay getting care that you need.

“The drawback of being a Maximizer is that you may get care and/or spend money that you didn’t need to, which may cause more harm than good.”

Dr. Scherer was also one of the co-authors of a study on cardiac treadmill stress tests  (familiar to all of us heart patients) in which we exercise on a treadmill or stationary bike to increase our heart rate enough to see if exertion causes changes in ECG results that are part of the test.(2)  This non-invasive test is often recommended when patients first report chest pain or other cardiac symptoms in the Emergency Department.

The study recruited patients with low-risk chest pain who had arrived in the Emergency Department and were eligible to get a cardiac stress test before being discharged from the hospital.  Each participant first watched a 7-minute video with information about low-risk chest pain and the probabilities of results and outcomes following that stress test. After the video, participants answered a one-question survey about their intention to go ahead with a cardiac stress test  – or not.

In this particular study, about 25% of participants were Minimizers who decided not to have the stress test, while the Maximizers who decided they would go ahead with the test accounted for 75%.

Interestingly, there was no direct connection found between Minimizer-Maximizer preferences and/or health beliefs after watching that informational video. In other words, if you’re a Medical Minimizer (“I’m just not a pill person!”)  – you may be unlikely to change your mind no matter how many informational videos you’re shown.

The researchers concluded:

“Patient perspectives and preferences may be different and require different strategies. For example, in our study, some patients voiced concerns with getting health care interventions, consistent with a Minimizer perspective. These associations are present even though individuals preferring more health care are typically no more ill than those preferring less.”

Since the 1950s, behaviour scientists and social psychologists have also been using what’s called the Health Belief Model to help explain why patients behave the way they do.(3)  

Health beliefs can also influence how we make medical decisions, based on our personal perceptions of  illness or disease.  For example:

  • Perceived susceptibility – How likely am I to actually be diagnosed with this condition?
  • Perceived severity – If I am diagnosed with this condition, what are the potential medical consequences (death, disability)?  What are the potential social consequences (family life, relationships)? And what happens if I leave the condition untreated?
  • Perceived benefits – How effective are the various available options at reducing the threat of this condition (or curing it?)  Would choosing early detection or treatment be beneficial – or not?
  • Perceived barriers – Would obstacles when choosing this treatment (expense, distressing side effects, pain, time requirements, inconvenience) be worse than any benefit I might experience?
  • Cue to action – Which internal cues (my own symptoms) or external cues (advice from others, illness of a close family member, media reports, etc.) might convince me to to accept a specific health action?

These perceptions seem important for prescribers to keep in mind – especially if you’re sitting across from a Medical Minimizer who believes she’s too young/too fit/too healthy to worry about ever having a heart attack, or too busy to bother tracking her blood pressure number.

♥

 Thank you to cardiologist Dr. John Mandrola for reminding us of Medical Maximizers and Medical Minimizers.  And here’s one of my favourite Mandrola essays – about the best tool for treating atrial fibrillation.

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  1. Laura Scherer et al. “Medical Maximizing-Minimizing Predicts Patient Preferences for High- and Low-Benefit Care”. Medical Decision Making 2020, Vol. 40(1) 72–80L
  2. Foy Andrew J, Bucher Ashley, Van Scoy Lauren J, Scherer Laura D.  “Medical maximizing-minimizing preferences and health beliefs associated with emergency department patients’ intentions to take a cardiac stress test after receiving information about testing”. 2022 | Volume:  6 | Issue Number:  4 | p267-2752
  3. Health Behavior: Theory, Research and Practice, Chapter 5, “The Health Belief Model”, Celette Sugg Skinner et al; Editors: Karen Glanz et al. John Wiley & Sons, July 1, 2015.
Image: ChenSpec, Pixabay

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NOTE FROM CAROLYN:   I wrote more about heart patients and medical decision-making in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local library or favourite bookshop (please support your independent neighbourhood booksellers) or order it online (paperback, hardcover or e-book) at Amazon –  or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

Learn more about attending this annual conference April 28 & 29, 2023 (see my April 4th comment below for specific registration steps if you’re a heart patient interested in attending virtually at no cost!)

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Q:  Are you more of a Medical Minimizer or a Medical Maximizer?

♥

Published by Carolyn Thomas

21 thoughts on “Medical Minimizer or Medical Maximizer: which one are you?”

  1. Pingback: Health Understandings

  2. Hello Carolyn,
    I was a minimalist waiting months to get help for chest pains. Now I guess you can say I am a maximizer.

    I take my pills on time each day with an hour in between my thyroid pill and heart pills. Because of complications from infections in my lungs, I am getting CT scans all the time. And now trying to regulate my thyroid blood test every 2 months.

    If it was not for my open heart surgery I would most likely not have followed up on the thyroid.

    I will wear my Medical Maximizer with pride.

    Liked by 1 person

    Reply

    1. Hello Susan – what an interesting comparison between your thyroid and then your cardiac diagnoses.

      As I said in response to another reader Kathleen’s comment (below) “Being diagnosed with heart disease can make a situational Maximizer out of the average Medical Minimizer!”

      It sounds like you’re being extra careful while trying to keep both conditions stable. Good luck to you!

      Take care. . . ♥

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    1. Hi Marline – on the conference link https://cwhhc.ottawaheart.ca/summit – click REGISTER HERE.
      1. Complete ATTENDEE CONTACT INFO
      2. on SUMMIT REGISTRATION, select WOMEN WITH LIVED EXPERIENCE (this will open to a number of options: choose Woman with Lived Experience – VIRTUAL ATTENDEE – $0 )
      3. on HOW DID YOU HEAR? add Heart Sisters blog – myheartsisters.org
      4. click SUBMIT REGISTRATION

      That should do it!

      Good luck with this! ♥

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  4. I would say I’ve fluctuated between being a minimizer and a maximizer my whole life depending upon the situation. I’ve always seen myself as “not a pill person” and I was proud that up until my heart attack I wasn’t on any regular medications other than the odd Advil or antibiotics from time to time. In the last decade I’ve gravitated towards what my naturopath recommended and saw that as complimentary to what the regular medical system provides. The hospital staff seemed rather surprised I wasn’t on any medications at all.

    I’ve become a maximizer and that’s because it’s my heart (no messing around with that!); I’m only at the 3 month mark since my heart attack so it’s still fresh and fear inducing for me. I keep reading and researching and I’ve learned to ask more questions of the clinic dr until I get my turn with my cardiologist who as it turns out is so backlogged he can’t see me at the 12 week mark but instead it will be more like 15 -16 weeks – not exactly what an anxious heart patient wants to hear.

    I must admit I’ve become an avid tracker of BP and heart rate etc. throughout the day and I justified getting myself an Apple Watch to help me track. Although I’m probably overdoing it with tracking, it has led to the regular dr adjusting medication so that’s one benefit of being a maximizer at the moment. I’m looking forward to the phase when I can relax more and worry less. Is that another pill ? 🙂

    In all seriousness though, I know these things take time. . . and I’m grateful for your blog!

    Liked by 1 person

    Reply

    1. Thank you Kathleen! I think being diagnosed with heart disease can make a situational Maximizer out of the average Medical Minimizer! No wonder you’re “not messing around” with your meds at only 3-months post-diagnosis. That’s too bad about needing to wait an extra four weeks for your follow-up cardiology appointment – but I’m glad you have the reassurance to be able to ask questions of the clinic doctor. Ask away!!

      After my heart attack, I was warned repeatedly by doctors and nurses in the CCU to never miss even one day of my prescribed anti-platelet drug called Plavix (which helps prevent future blockages inside newly implanted coronary stents). The hospital even gave every stent patient being discharged a medical-ID bracelet that read “DO NOT STOP PLAVIX”! That’s a pretty explicit warning to wear every day!

      Good luck at your appointment with your cardiologist! Take care. . . ♥

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  5. What a really good topic to explore! I think there is also a parental/generational influence on this.

    Many post-war boomers were raised with the “I’ve had bigger cuts than that on my eyeball” attitude which may add to minimizing health issues until they get out of hand. I fight this little inner voice any time I need testing etc. for a couple of other health conditions I have.

    I was diagnosed with Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) in 2010 and I went to MD Anderson for a 2nd opinion.

    The first opinion was to start Chemo after multiple scans etc, but MDA said let’s watch and see how it is actually acting after they ran their scans. I was put on Watchful Waiting and am still on it with yearly monitoring.

    What I have learned to do beyond the panic phase when health issues happen is gather information through research, (understanding a little of the vocabulary) talking with the doctor, and then being involved in the plan of care.

    Being your own best advocate is the most important health decision you can make, (especially if you have a cut on your eyeball!😏)

    Liked by 1 person

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    1. Hello Kathryn – very astute parental/generational observation! A popular poem that was written in the 1950s (just after the war) advises:

      “Don’t tell your friends about your indigestion. ‘How are you?’ is a greeting NOT a question!”

      I grew up with that motto in my own family, for sure. Minimizing a health issue was almost a matter of politeness back then. Don’t make a fuss. Don’t be a bother!

      And researchers now tell us that women tend to exhibit “treatment-seeking delay behaviours” significantly more often than our male counterparts – which may help to explain our relatively poorer outcomes for the same diagnosis compared to our male counterparts.

      I now tell the women in my Heart-Smart Women audiences that their only job is to become the world experts in their cardiac diagnoses – so I really like your three steps (research/talk to your doc/get involved with the plan!) in becoming your own best advocate. Especially for eyeball cuts! 😉

      Take care, stay safe. . . ♥

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  6. I too, read Mandrola, and trust his opinions.

    And so easily spotted in my own small family of 5. And, being a Nurse Practitioner doesn’t keep me from my own minimizing approach. 🤷‍♀️

    Liked by 1 person

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    1. Hi Lynn! I miss Dr. M’s regular blog articles (they’re archived now, as he’s doing other forms of medical writing these days, but it takes some sleuthing to track down specific articles on specific arrhythmia topics now).

      I do wonder if nurses tend towards minimizing behaviour (the more you know. . . ?)

      Thanks for weighing in here today – take care! ♥

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  7. I’m a ‘minimiser’ because of lack of follow-up. When side effects outweigh any perceived or lack of reduction in cardiac symptoms, why are you going to stick with them?

    I would take any medication that alleviated my cardiac symptoms. But when I’ve been prescribed medication, I might be told common side effects, but no one – not one GP or cardiologist – has sat down with me and told me what are most common side effects, what are rare ones, which ones are serious and if I need to stop taking medication, which side effects will fade over time as the body adjusts, how long does it take to adjust to the side effects. What are symptoms the medication isn’t working (beyond the obvious – no reduction in symptoms) and what are symptoms that it is working but the dose is wrong (too low or too high?).

    And not one cardiologist or GP has scheduled a follow-up 2 weeks later until we get it right. Of course..they don’t have the time.

    And if any follow up is scheduled, it is like 3-6 months away. Generally, because I have a complete absence of knowledge of side effects and handling of them, yes, I do stop taking the medication – within days (if the side effects are horrendous) or weeks (because of no perceived benefit and too many side effects).

    So if a cardiologists wants minimisers to stop being minimisers they need to be more upfront about the side effects and more proactive about follow-up – and within 2 weeks of prescribing medication, not 6 months or more.

    I suspect I might be on a successful regime now if the cardiologists followed up and persisted until it was right. For example, there are 3 types of calcium channel blockers and at least 3 ways to take nitroglycerin. I have been tested on one of each and when it didn’t work, they’ve gone, ‘oh well…’ until after doing one sample of each group of drugs over a period of 2 years, I suddenly find myself in a no man’s with no upcoming appointments with a cardiologist and no treatment.

    But to expect patients to stick to a drug regime with no follow-up or follow-up scheduled months away, crap side effects and no idea if the drug is working but too low a dose, etc, there will always be minimisers like me.

    Liked by 1 person

    Reply

    1. Hello travelblips – you seem to be the perfect client for your local pharmacist!

      Pharmacists are a goldmine of expertise on every possible drug, side effect, stopping, starting, etc. – and they have far more training in evaluating emerging drugs and most importantly, how these may or may not interact with other drugs than your cardiologist or GP have.

      Where I live, every prescription drug also comes with a detailed patient information fact sheet so we can do our own homework, but in my opinion, pharmacists are an under-appreciated resource for all heart patients! If you do want to know more, they’re out there and happy to book a Medication Review appointment with you.

      Take care. . . . ♥

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  9. Hi Carolyn,

    I thoroughly enjoy reading all your installments! I share them with my peer and Facebook groups. I also am a presenter at this year’s Summit, so hopefully we can meet.

    The in-person Summit is not free to women with lived experience this time around. In person is $250 for one day, $300 for both days.

    Free for virtual attendance!

    Thanks!!

    Liked by 1 person

    Reply

    1. Hello Risa – thanks for your kind words. I did mention that the free Summit registration is for virtual attendance. Because of ongoing cardiac symptoms, I’ll be presenting virtually, too – from my kitchen! – so won’t be meeting you in person this time.

      Have FUN at the Summit, and good luck with your presentation! ♥

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  10. Thank You! .. ♥️
    I’m not suggesting of course (see comment below) that’s it’s the best course for everyone, but it was for me…

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    1. Thank you for weighing in here, Dr. S – I had included a mention of that Groopman/Harzband book in my original draft of this post, and deleted it only because of space. I think I’ll put it back in now!

      Meanwhile, congratulations on your new book!

      Take care. . . ♥

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