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.

Batting .400: Baseball Good, Doctors Not So Good

Brian Goldman, an Emergency Medicine physician in Toronto, discusses mistakes in medicine including the causes (e.g. cognitive bias) and the culture of denial that prevents us from openly and honestly discussing and, therefore, reducing the risk of mistakes.  He mentions the VA in the 200+ comments below the talk on the TED website: "The VA has pioneered the widespread use of decision support - including comprehensive use of clinical practice guidelines - to get MDs to consolidate their practice patterns around evidence-based approaches. The result is that VA hospitals are treating patients better and at lower cost."   Link for iDevices: Brian Goldman TED.com

Fallor ergo sum - I err therefore I am

Kathryn Schulz is the author of Being Wrong: Adventures in the Margin of Error.

"One can't understand everything at once, we can't begin with perfection all at once! In order to reach perfection one must begin by being ignorant of a great deal. And if we understand things too quickly, perhaps we shan't understand them thoroughly." — Fyodor Dostoyevsky

James Bagian on medical error

Kathryn Schulz has a wonderful Q&A with James Bagian, director of the VA national center for patient safety, at the Slate blog "The Wrong Stuff". Read it all, but I especially enjoyed his thoughts on blame, punishment, and the perverse incentives that can be introduced by public disclosure.

Kathryn Schulz is the author of the book, Being Wrong: Adventures in the Margin of Error. I haven't read it, but I think I'll check it out.