Simone, Joseph V.
I was in my late 30s or early 40s before I was willing to call them “lies.” I think I had to reach a certain threshold of maturity, experience, and open mindedness to accept the lies as such. These are not “white lies,” largely innocent with no damage done to another person (damage to the liar is another matter). Some of these are frank lies, others are half-truths, and still others are statements meant to mislead or to convince the patient that only he/she is responsible for a decision.
The statements listed are not always lies, but too often they are. When there is a major unspoken reservation after one of these statements, it is my belief that it becomes a lie. Here are a few of the relatively common lies in medicine.
#1: We got it all. This is the king of all lies in cancer. It is not uncommon today for a cancer surgeon to tell a patient or family member triumphantly that “we got it all.” Although it is justified in some instances, for most carcinomas this is blatantly wrong and biologically impossible, since many carcinomas are systemic in nature and micrometastases remain in the patient even with “clear surgical margins.” It misleads the patient and family into thinking the patient is cured.
Surgeons who tell this lie defend themselves by saying, “What I meant was that we got all of the tumor we could see at surgery,” or, “Of course, the patient will need chemotherapy for the remaining microscopic cancer.”
So why didn't he say that? I hear various explanations: “No need to burden the family and patient at this time,” or, “You never know; I might have gotten it all. I had a patient once that…”
This introduces the second great lie:
#2: You never know. When I made rounds with fellows and junior faculty and we were faced with a difficult diagnostic or therapeutic decision, I would ask each to give his or her opinion and to explain the choice. One junior faculty member back in the 1970s often chose what seemed to be an excess of additional diagnostic tests or images, and he often chose therapeutic options that had a next-to-zero chance of success. When his choice was challenged he would say, “You never know,” meaning this might be the one in a million case in which there is a useful or positive result.
It drove me nuts. I wanted to grab his lapels and shake him saying, “Of course we can't be positive about any action we take; this is biology and medicine about which we are woefully ignorant, but we must apply what we know to make the best reasoned choice we can. You are using sloppy logic and, even worse, you are lying to yourself and possibly to the patient as well.” I never did show any emotion or grab his lapels (I would have later in my career).
Unfortunately, this lie is still used today, if not in so many words, or even with no words at all. The patient with the third or fourth recurrence is offered an ineffective therapy because, “You never know,” and the lie is compounded when there is a substantial financial incentive to give the therapy. A related big lie follows:
#3: I did it because the family insisted on more therapy. This is a common excuse for giving or doing something that is clearly not in the patient's short- or long-term best interests. It is often excused by the confusion of the nature of “patient choice” and sound medical advice or practice. Patients and/or families should be participants in decisions so they may express the boundaries of action they are most comfortable with. But the doctor is duty bound to do the same.
To blame the family for highly questionable interventions is an abrogation of responsibility by the doctor. It is very hard to say no to a desperate patient or family; there are many difficult actions physicians face in the normal course of their days. Nobody said it would be easy.
#4: It's your decision. This is a variant of the preceding lie. There is no question that doctors influence patients' decisions. Doctors have biases that may be based on scientific data or a common standard of practice, and it may therefore be reasonable to make a strong recommendation.
But in some cases the bias is personal, such as wanting to get more patients on a clinical trial, to do more surgery, to increase revenues, or to avoid having to deal with a difficult patient. In these cases, how the choice is presented along with the enthusiasm and salesmanship of the doctor can make it far more unlikely that the patient will choose an alternative option, even when at the end of the explanation the doctor says, “It's your decision.”
In a technical sense, it is indeed the patient's decision to go forward, but the strong conviction of the doctor has severely reduced the patient's degrees of freedom. As noted above, a strong recommendation is sometimes indicated, but when those instances are based on a personal preference or bias, one must be extra careful to balance the bias through information and transparency.
#5: He's a good doctor. Patients require referrals to specialists and most often depend on their current physician to recommend one. Physicians usually refer to specialists that they know personally or know to be competent by experience or word of mouth. But they may refer a patient because the specialist is a golfing buddy or in the same building or a business partner. The specialist may be quite competent, but one must ask oneself the simple question: If the patients were members of my family, would I send them to this specialist?
Or when one tells the patient, “She is a good doctor,” does he really mean, “She is a good enough doctor,” or “He can probably handle this case; it isn't so complicated?”
Referral relationships are fragile and are often influenced by non-medical issues. One must be diligent to avoid exposing patients to unnecessary risks in order to satisfy a social or business obligation.
Thus, while each of the above statements can be used honestly and justly, they are too often used for more negative and sometimes shameful reasons. The test is the motivation found when being honest with oneself and, at the very least, facing the fact when one is not.
Collection of Dr. Simone's ‘OncOpinion’ Essays in Book Form
Dr. Joe Simone's new book, Sustaining the Dignity and Nobility of Medical Care (ISBN 978-0-9799274-0-9), has now been published. The 220-page soft cover book is a collection of essays that first appeared in Oncology Times, speaking to the challenges, opportunities, and nobility of being a doctor. The writing is to-the-point and accessible and speaks to the hard truths of professional life.
Additional and ordering information is available at www.editorialrxpress.com; firstname.lastname@example.org
New Pancreatic Cancer Guide
The Lustgarten Foundation for Pancreatic Cancer Research has released Understanding Pancreatic Cancer: A Guide for Cancer Patients and their Caregivers. The handbook provides the most recent information about many aspects of pancreatic cancer such as symptoms, diagnosis, staging, treatment, clinical trials, supportive care, and research. A glossary of terms is provided to aid readers, along with an appendix that contains a list of resources and the best cancer facilities, as designated by the National Cancer Institute. The guide is available online and in hardcopy by request at www.lustgarten.org.
© 2008 Lippincott Williams & Wilkins, Inc.