Did you know that your brain is trying to prevent you from receiving the best medical care for your blood clot or clotting condition?  Your brain is faced with an uncountable amount of information every day.  In order to process all of this information the human brain has developed rules and ways of thinking to allow it to quickly sort, process, and act on massive amounts of data.  While our brains do a miraculous job handling this data they also can lead us to false conclusions that can slow our healing and put us at a greater risk for significant health problems in the future.  In today’s article we are going to review how the brain processes information and look at some of the most common errors in thinking that may negatively affect your medical care.

Humans make mistakes in thinking due to how the brain handles information.  The name for these errors is cognitive bias.  Research has shown that learning about cognitive biases can help you make better decisions.  Better decisions will lead to better healthcare, faster healing, and a lowered risk of future clots.

Recency effect
Have you found yourself looking back into the days and weeks before your clot to try to figure out what caused it?  Be careful, you may find your brain suffering from the recency effect.  Our brains tend to look at how close together two things happened in time.  The more recently something happened the more likely we are to think that it was the cause.  Maybe you ran a marathon, started a new medication, or took a supplement in the days leading up to your blood clot.  While these might be the cause of your clot it is also possible that genetics, pregnancy, or other long term risk factors were the cause of your clot.  It is also possible that your clot was caused by multiple risk factors rather than a solitary event.  It is important for you and your medical tem to evaluate all of your risks rather than the ones that may have just happened.

Confirmation bias
Did you jump on the Internet to see what caused your clot?  Be careful, we tend to favor information that supports what we already believe.  Humans have a difficult time believing evidence that tells them what they think is wrong.  Let’s look at an example.  Sally has a blood clot and her doctor puts her on warfarin, an anticoagulant.  Sally knows that warfarin is also used as rat poison so she is very uncomfortable with this medication.  She goes to the Internet to read about warfarin.  She reads five articles that state that warfarin is safe and one article that states warfarin is dangerous.  Sally favors the one article that states that warfarin is dangerous because it supports what she already believed.  She goes to her doctor and asks to switch medications.  The human brain doesn’t like to be wrong.  When doing research it is a good idea to try to prove yourself wrong rather than right.

Faulty generalization
Looking at other people’s experiences can be comforting but it can also cause errors in thinking.  Human brains tend to over estimate how many times something happens.  We often think that if we meet one person that had something happen this must be true for everyone.  Here are some examples. 

Sam’s mother died of a brain bleed while taking a newer anticoagulant.  Bob’s mother takes warfarin and has no side effects.  This must mean that warfarin is safer.  In reality some of the newer anticoagulants have a much lower risk of brain bleeds.  In this example I don’t pay attention to the fact that I need to look at thousands if not millions of examples to know which medication is safer.  One example does not tell me how other people overall react to a medication.  This is why we need thousands of people in drug studies.

Mary had a blood clot while on birth control.  It must be very dangerous.  Again I am looking at just one person.  I did not consider the millions of people who didn’t have a clot on birth control.  Pregnancy is a larger risk factor than birth control.  I missed that information though because I only focused on my friend Mary.

To overcome this error in thinking make sure to read studies that look at thousands of people.  Ask your doctor for advice about medications.  Doctors are trained to read medical papers and understand risk factors.  It is a good idea to ask your doctor why he or she favors a treatment or preventative measure.  Feel free to ask for the research so that you can be confident that your healthcare decision is based on the full picture rather than just one or two people.  Be careful on support groups.  They are a great resource but make sure that you aren’t taking a few people’s experiences and favoring them over well researched information.  Just because it happened to one person doesn't mean that it will happen to you.

Negativity bias
We tend to pay more attention to bad news versus good news.  When we see a lawyer add on television for malpractice we believe that this is happening everywhere and we can’t trust the medical community.  We hear about blood clots or bleeds being associated with treatments and we don’t see the millions of people who benefit from these treatments.  We hear about people who struggle to recovery from a pulmonary embolism and don’t see those who heal in two weeks.  We see our own misery and don’t see that we can ever heal.  I recommend that you try to intentionally focus on the positives.  Keep a list of five good things that happen a day.  Chart your progress that you make in recovery on a daily or weekly basis.  Pay attention to those people in support groups who are thriving.  These will lighten your heart and help you to avoid the negativity bias.

Wrong authority
We don’t do a good job knowing who to trust.  We may find advertisements and peers better sources of information than our doctors.  Make sure that you use your medical team as your main source of information.  It can be difficult to know which articles online can be trusted.  If you want to read more on a topic you can visit a library and ask the librarian for help in finding information from reliable sources.  If you happen to have a medical school near you then take advantage of it!  It will have a medical library with a trained medical librarian.

If you struggle with trusting your doctor try these ideas:

1. Ask questions until you know why your doctor feels a certain diagnosis or treatment is correct
2. Ask why NOT the alternate diagnosis or treatment
3. Seek second opinions from other doctors
4. Ask your pharmacist
5. Find a support group or questions and answer service that is staffed by doctors
6. Ask different types of doctors and have a variety of doctors on your team (OBGYN, GP, internist, hematologist, radiologist, pulmonologist)
7. Consult sites that are written for doctors by professional organizations
8. Use sites that end in .gov or .edu for your research
9. Get a doctor that you trust

How to overcome biases in thought

1. Look for research that disproves your belief and seriously consider it.
2. Don’t take one person’s story and use it as the basis for your treatment.  Use professional research and the opinion of your medical treatment team as the basis of your treatment decisions.
3. Make sure to take note of the positives as well as the negatives.
4. Don’t panic when you hear lawyer ads.  You can use them as a sign you should research something more.  Do not assume that because there is a malpractice ad that there really is a huge problem with a treatment.
5. Look at research statistics not individual experiences.
6. Use reliable sources.  Many end in .edu or .gov.  A librarian can also point you towards reliable places to get information.
7. Find professional organizations that deal in clots.  The Clot Spot has a great list of these in the resources section.
8. Don’t panic!

After a clot you have a number of anticoagulants available for treatment.  Currently, there are three anticoagulants that are approved for the treatment of pulmonary embolism and deep vein thrombosis.  These three medications are Lovenox (enxaparin), Coumadin (warfarin), and Xarelto (rivaroxaban).  This article will review what I know about each medication.  Remember to discuss all of your options with your doctor.

Medication Descriptions:
Coumadin is the oldest medication on the list.  It blocks vitamin K.  Each person needs a different amount of Coumadin to achieve a safe range of medication.  This amount of medication changes daily based on diet and other medications.  Patients must eat a consistent amount of vitamin K daily in order to have the right amount of Coumadin.  This medication is very picky.  Too small of a dose raises the risk of clots and too high a dose raises the risk of a bleed.  Because the dosing must be very precise in order to be safe and effective, people who take Coumadin must have routine blood tests.  These tests may be done at home by working with a doctor to purchase a home testing machine or they can be done at a doctors office.

Lovenox is an injection that can be given at home by the patient.  It is self-injected into the fat around the abdomen.  Typically patients will do injections twice a day.  Lovenox doses are much more consistent from patient to patient.  For this reasons you will not need routine blood work done while you are on Lovenox.  Lovenox is much more expensive than Coumadin, but you will not have to pay for weekly blood testing.  Lovenox has no dietary restrictions.  You can eat a massive salad one day and no vitamin K containing foods the next day without having to worry about your medication levels.

Xarelto is the newest of the approved medications.  It is an oral medication.  It has no dietary restrictions.  It also is very consistent from patient to patient so it doesn't require routine blood work.  As it is new, there are no generic versions of this medication.  Payment assistance can be found on the manufacturer's website.  Like Lovenox, Xarelto has no dietary restrictions.

Effectiveness of the Different Anticoagulants:
Studies have shown that all three medications are about equally matched in effectiveness when they are used as directed.  As directed is very important to note.  If you are prone to missing doses, the newer anticoagulants aren't for you.  The new anticoagulants must be taken more frequently and they leave your body quickly.  Missing a dose of medications like Xarelto will put you at a high risk of clotting. Coumadin has similar problems.  If you can't maintain a high enough level of Coumadin, you risk a clot.  If you don't feel that you can track your vitamin K intake or if your INR test results are showing a lot of fluctuations, you may want to ask your doctor about switching to a different medication.

Bleeding Risk:
Coumadin can have a high risk of major bleeds if the blood levels are not kept within range.  This risk goes up with age and with certain health conditions.  Out of the anticoagulants, Coumadin has the highest risk of cranial (head) bleeds.  Coumadin takes 5-7 days to leave your system completely.  If you start to bleed or need surgery an antidote will be needed.  This can cause problems.  Luckily, years of use have established many FDA approved means of reversing Coumadin's anticoagulant effect.

Lovenox has a similar risk of bleeds.  It also takes a number of days to leave the body.  For this reason it should not be used before surgery.  Lovenox also has a number of FDA approved antidotes to reverse bleeding.  Diet and dosing will not impact the bleeding risk.  The biggest risk of bleeding on Lovenox is caused by heparin-induced thrombocytopenia.  If you have ever had heparin-induced thrombocytopenia let your doctor know immediately.

Xarelto has a much lower risk of cranial (head) bleeds than the other two options.  It does carry a higher risk of stomach and intestine bleeds.  Other bleeding risks are the same whether you take Coumadin, Lovenox, or Xarelto.  Xarelto leaves your body quickly.  This can help in a bleeding situation.  Currently there are no FDA approved methods of reversing Xarelto.  There are some unapproved methods that can be used to reverse bleeding.  The FDA is reviewing some possible methods of reversal so there may be an antidote in the near future.  If you are having problems keeping your INR in range, Xarelto may put you at a lower risk of a major bleed.

Other Side Effects:
Everyone's body is different.  You may find that your have side effects other than a bleed.  If you are having something happen that is uncomfortable or unfamiliar I highly recommend talking to your pharmacist and medical team.  Switching medications may make you feel a lot better while keeping you safe.  If you switch and the symptom hasn't gone away, talk to your doctor as you may have another health problem that needs to be addressed.

Other Things to Continue:
If you have other health issues let your doctor know.  Pregnancy, cancer, kidney or liver problems, and other health issues can change which medication is recommended for your situation.

Anticoagulants are a life saving class of medications that can help you to survive blood clots.  When used correctly they are very safe.  Very few people will have a life threatening bleed.  For most people the risks of a clot far outweigh the risks of a bleed.  While you will hear law firms advertising law suits against the newer anticoagulants, they are proving to be very safe and effective medications.  Your doctor can review your options with you.  Ask lots of questions and feel free to ask multiple pharmacists or doctors.  These professionals are the best source of information about medications.

After a blood clot, tests can be run to determine if you have a condition that makes your blood clot more easily than the majority of the population.  These conditions are often referred to as clotting conditions, thrombophilia, or hypercoagulable states.  Testing for these conditions will not be able to predict who will and will not have a clot.  About half of the people who have a clot will have no known cause.  This means that the blood work would show no clotting conditions.

Testing for thrombophilia is useful when deciding the length of time a patient will be on anticoagulants.  The problem with anticoagulants is that they are risky.  You only want to be on anticoagulants if the risk of clotting is larger than the risk of a life threatening bleed.  Testing for thrombophilia will give you more information so that you and your doctor can determine which risk is more acceptable for you.

To determine if thrombophilia testing is right for you, you should:

• Ask your doctor if having thrombophilia would change his or her recommendations about the amount of time that you will take anticoagulant medications.  If the test will not change treatment, the test is not needed.
• Talk with your doctor and insurance agents about the impact the findings may have on your ability to obtain life insurance.
• Consider your age.  Many recommendations state that individuals under the age of 50 that had a DVT or PE without a significantly large risk factor (abdominal surgery, bed ridden, cancer, or other major risks) have tests run to see what may have caused the clot.
• Consider your risks.  Can you and your doctor identify any MAJOR risks?  A major risk may be able to be eliminated so that the clot doesn't repeat.  If you only had a minor risk (weight and birth control are examples) there is a good chance that something else contributed to your clot.
• Ask your medical team what they feel are typical, minor, and major risks for blood clots and figure out where you fit into that list.
• Consider what risks will be in your future.  Are you thinking about birth control, infertility treatments, cancer, hormone replacement, frequent long haul airplane trips, or any other big risks?  You may want to know if you have a clotting condition that will put you at further risk.
• Is there a family history of clotting or miscarriage?  If there is, let your doctors know!
  

Think about your history, the costs, risks, and benefits.  Medical testing seems harmless but it can have unwanted effects.  If you need help deciding about testing please talk to your primary care provider and consider requesting a hematology consult.  Feel free to get a second opinion.  Many times doctors will write off a clot as a simple case of birth control pills, weight, or travel when there might be more to the story.  If you haven't experienced a recent major risk factor there is a good chance that there is more to your clot's story.