Thursday, February 9, 2012

Lying About Prognosis Might Not Be Lying

There is a lot of chatter (or here) about Lisa Iezzoni's study on physician openness and honesty, that was recently published in Health Affairs.  We've discussed the importance of disclosing medical errors numerous times, as well as the importance of disclosing financial conflicts of interest, so physicians who aren't honest in those domains, will get little sympathy here.  However, one aspect of the survey findings, I think, deserves more discussion, namely the disclosure of prognosis.

To quote from the article: "...more than half said that they had described a prognosis more positively than the facts warranted."

Is this really "lying"?  What is the importance of disclosing mean, median or mode survival?  Will patients or families even understand the difference?  How do you explain a normal or skewed survival curve?  If you can't describe the distribution or they don't understand it, is that dishonesty? Importantly, how does this all impact "hope"?

One article, written many years ago (1985) by Stephen J Gould, the Harvard evolutionary biologist, does a better job describing why "The Median Isn't the Message" than anything I could write. He tells how he reacted to his 1982 mesothelioma diagnosis. He lived until 2002. This essay has been highly influential to me throughout my medical career.

3 comments:

  1. From a patient point of view who had to hear the bad news this past week- we do best with frank and jarring honesty. We have friends who see the same specialist and don't want the frank and jarring truth, they prefer the specialist to hint...and gently sugar coat everything.

    We both adore the same Specialist. What makes her "good" at working with her patients is she makes no assumptions(even in Public School, many of us learned the concept of mean,median or mode as early as 4-5th grade.) She also recognizes the differences in each family dynamic.

    If a Dr. is not strong in the human element, his duty lays in making sure his patients understand- if that means honest and blunt so be it.

    Thanks for making me think this morning- as a patient I would not have even thought about this as a skill, or concept that was taught or discussed.

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  2. Why would we expect physicians to be different than the rest of us? Healthcare providers don't give prognoses simply because they cannot do so accurately and the wrong prognosis time and time again erodes ones ego. Doctors tell lies when it suites them and to think that they somehow know better and do so in our best interests clearly put you within that group of people who feel comfort in diverting responsibility to others; which is fine, but don't make-up stories about it.

    I find a more pressing question about the recent study that about forty-percent of the physicians that received the study pocketed the twenty bucks and didn't bother to respond. Once again, human nature. You may like to think healthcare providers are altruistic and to some extent they are but really, how can you ignore who we are.

    P.S. We're all going to die, it's a given, learn to live with it and act accordingly.

    Cheers!

    Michaeal

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  3. This isn't making up stories. It is suggesting that giving people hope, i.e. focusing on the right-skewed tail is probably the best thing you could do for the patient clinically (hope) but ALSO is a more honest interpretation of the data. Focusing on central tendency measures like mean or median and acting like they are the "truth" may be the true deception and not just in medicine. Saying things like 'we are all going to die', while true, ignores factors like quality and quantity of life.

    The real tragedy of society and media is the tendency to focus only on the negative aspects of people and research studies. The point of my post was to shed some light on an important aspect of shared decision making between doctor and patient. I probably should have gone further to suggest that including prognosis discussions in the article was incorrect and if I was reviewing the paper, I would have suggested that the authors remove prognosis discussions from their estimates of lying.

    If you haven't already read Stephen Gould's article, I think you might like it. I had the chance to ride the T with Dr. Gould when I was living in Boston and thanked him for his article 15 years after he'd written it. It was probably one of the highlights of my time in Boston and our brief discussions further strengthened my belief that only telling patients "they only have 8 months to live" if that is the median survival of their condition, is almost certainly lying to them.

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