Simone’s OncOpinion
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.

Tuesday, February 28, 2017

What influences us to choose the specialty of oncology has always interested me. Today, there are many training programs and role models for medical students and house officers to emulate. But when I completed my internal medicine residency in 1963 and started a fellowship in pediatric hematology (that's another story), there were few formal training programs in oncology; ASCO did not exist; there were no subspecialty board certifications for hematology, medical oncology, or pediatric hematology/ oncology. At that time in the late 1950s and early 1960s, there were many locations where only radiation oncologists and surgeons gave chemotherapy.

The relatively few full-time medical oncologists often arrived at their professions via other medical activities. The migration from hematology was the most common, but others came from a variety of specialties and activities as diverse as endocrinology (studies of hormone-dependent cancers) and from World War II studies of toxic compounds like mustard gas. As with physicians today, the choice of subspecialty in the early 1960s was influenced by a mentor, a patient, a family member, personal traits, or by unique or serendipitous circumstance. In my own case, the example and mentoring of Donald Pinkel, MD, the first director of St. Jude Children's Research Hospital, made me a committed oncologist, scientifically as well as clinically.

Choosing medical or pediatric oncology was unusual and no easy matter in those days: medical and pediatric oncology were viewed with condescension by the pooh-bahs of academic medicine because they were "unscientific;" medical and pediatric oncology were mostly poor sister add-ons to hematology in medical schools (they thrived mainly at cancer institutes); the foundation of clinical trials was being laid with fits and starts; diagnostics for most cancer were primitive by today's standards; disfiguring and debasing gonzo surgery, including "super-radical" mastectomies and the fabled "hemicorpectomy," was common; and the prevalent radiation oncology equipment was the cobalt-60 machine.

But the most defining feature of that time was the treatment—it wasn't very good and the great majority of patients died relatively quickly. Because of the stress of dealing with so many dying children, it was not unusual for pediatric oncologists to change specialties; some of my own colleagues switched to radiology, dermatology, neonatology, and radiation oncology.

While the support of mentors, our personality type, and the other factors noted above often influence our career decisions, I believe the picture is more complex. I would guess that each of us could easily recall distant and seemingly unrelated personal experiences that instilled in us "life lessons" that helped us navigate this challenging field. Such recollections are seen, of course, through the fog of passing years. So with selective hindsight and a bit of puckish reconstruction, I have listed in roughly chronological order some of the character-shaping lessons that I believe helped me to choose in 1967 to become a full-time pediatric oncologist.

Family Culture

I attribute my father's influence for my values. But in this context his example of a deep mistrust of material possessions and of living within or below one's means served me well and later provided me the option of enabling me to take extended postresidency training and an academic career which, of course, I did. The lesson: Live below your means and keep your options open as long as possible.

High School Football

All the coaches were "old school" in the early 1950s. Pre-school summer practices were brutal: twice a day in full pads and uniform in the August heat and humidity with no drinking of water during practice (I did say old school), and punishing scrimmages to see who could "take it." We had snug-fitting leather helmets with no facemasks; I think all they protected was our ears from being torn off while blocking. We all talked about quitting, but few did. I wasn't a very good player and I rarely started, but I played well enough and the experience was invaluable. The lesson: I was capable of persevering under severely trying circumstances (handy insight for an oncologist).

Holding Retractors

Like many medical students, my choice of specialty changed several times before I made my final decision. I loved surgery…in theory. But after hours of holding retractors and doing all the other related chores (not very well), I decided that surgery wasn't for me. I didn't see myself getting enough satisfaction out of the operating room to make up for the rest of it. The lesson: The manual and technical aspects of medicine did not suit me as well as the intellectual. When I met the chief resident of the service, he said: "Do you want to be a cutting doctor or a thinking doctor?" He sifted me out with one question.

Homer

No, not the Greek poet. Homer was a 5-month-old African American baby under my care during the pediatric elective of my medicine residency. He was a beautiful, chubby, happy baby that was always glad to see me. He had pyloric stenosis that eventually was surgically fixed without incident. For reasons I can't explain, caring for Homer helped me realize how much I liked taking care of kids; I still think of him years later. The lesson: Patients had much to teach us about ourselves, including what direction to take in our medical development.

Serendipity

Three examples: I moonlighted to support myself and my upcoming new family. I took call in an industrial clinic and later worked the night shift as a hospital lab technician; that stirred my interest in hematology, which ultimately led to a career in oncology. One of the best available hematology fellowships happened to be only two blocks from my residency institution so I could go to an interview at no cost; it also happened to be in a pediatric department (Irving Schulman, MD, an eminent hematologist, was chairman), which ultimately turned me into a pediatrician. A colleague in the department (Charley Abildgaard, MD) was asked to look at a "hematology" job at a place I had never heard of then, the 4-year-old St. Jude Children's Research Hospital in Memphis. He was a Californian and suggested that it might be a better fit for me. I subsequently spent 24 great years at St. Jude. Each of these serendipitous events had a profound impact on the course of my career. The lesson: Planning is important, but chance can play a major role in a career; one should keep an open mind and not plan too rigidly.

The Chicago Cubs

Finally, I learned to read newspapers for pleasure from the sports pages of the Chicago Tribune. The Chicago Cubs' games were broadcast all summer; there was no TV and the radio announcers' dramatic renderings of the play made me a passionate fan. I suffered many years of the Cubs' legendary futility—they last won a World Series in 1908 and last played in one in 1945, when I was a 10-year-old. And even after leaving Chicago, I could not remain completely detached from their fortunes or switch allegiance to another club. Maybe it was because I was born a few blocks from Wrigley Field. Maybe, as someone once said, a sports allegiance passionately held at 8 years of age is ingrained for life, like it or not. In any case, being a Cub fan entails accepting many defeats while retaining unquenchable hope. The lesson: Being a fan of the Chicago Cubs was excellent preparation for a life in oncology.​

In summary, we all can point to major influences that led us to become oncologists, but I believe there are many seemingly minor factors as well. These "minor" factors may in the long run have been at least as important as the "major" factors, if not more so … and certainly are more interesting.


Wednesday, January 25, 2017

I don't know much about Olympic swimmers or professional quarterbacks, but with my unscientific observation, I would guess the average top-notch swimmer probably peaks in competitive ability at about 20 years of age, give or take 4 years or so. I also would guess the average competitive professional quarterback probably peaks at about 30 years of age, give or take 4 years or so. By that I mean they will not consistently perform substantially better after reaching that peak. Subsequently, they will perform at about the same level for a while and some time later, slowly or rapidly, progressively get worse.

Barring a serious injury, they may still perform satisfactorily, but not at their historically best level. There are exceptions, of course, but the variations are most likely to be when the decline occurs, not if it will occur. A decline is inevitable.

As I have aged, I often have wondered when physicians reach their peak of skill as a doctor. To be clear, I am speaking of physicians as practicing doctors who provide ongoing care for patients on a consistent basis. Of course, this is not easy to measure (maybe impossible) so my attempts to tease this out cannot be a straight line because we have no quantitative comparatives, such as swimmers' race times and gold medals or quarterbacks' touchdowns and interceptions, to use as a gauge.

This is basically a personal reflection of my 5-decade span as a physician and as one who has observed, trained, worked with, and judged many physicians. My focus is on physicians as practitioners of the art and science of medicine face-to-face with patients, not as a chair of medicine, leader of a practice group, laboratory scientist, or any other related professional activities that physicians may enter.

The first challenge in this exercise is what is meant by peak? Peak of what? Surgical or other technical skills, diagnostic skills, compassion, knowledge? Wrestling with these questions led to my approaching the issue from an oblique angle rather than head on.

When I view the evolution of physicians' abilities, I believe there are at least three overlapping phases. The first is experience. This is the basis for all the rest. The next is intellectual insight, which combines experience and knowledge acquired from experience and indirectly from publications, meetings, grand rounds, colleagues, and students. The third stage is humility, knowing the boundaries of one's ability and the common sense to act accordingly. Humility implies that one is open to becoming wise, to acquiring wisdom. This is the opposite of the know-it-all.

Each of these three qualities can be, and usually are, expanded over time and each reaches a peak, often independent of the other two. For example, an experienced and knowledgeable surgeon with long experience and excellent technical skills may remain infantile when it comes to humility and tends to inflate the accolades he receives to justify acting beyond his experience, knowledge, and skills. I can think of examples for radiation and medical oncologists as well.

If a physician lacks one of the three pillars described above—experience, intellectual curiosity with knowledge, and humility—it would be impossible to reach a high level of medical practice. The peak of one's ability would not be "competitive" and it would be difficult to imagine such a practice being even satisfactory. The degree to which one raises his/her skill level in all three of these qualities will collectively determine the peak of skillful medical practice.

For this purpose, one may encompass all these qualities into a single "measure" (really an attribute) of peak ability and skill: wisdom. Experience, intellectual curiosity, knowledge, sensitivity to patients and their needs, and a measured balance of good judgment and humility contribute to what we might call, "medical wisdom," which includes the application of all three qualities.

Let's digress for a bit about "wisdom." First, here is a short poem.

The Road to Wisdom

The road to wisdom? Well, it's plain

And simple to express:

Err

and err

and err again,

but less

and less

and less.

—Piet Hein (Danish poet)​

This reinforces the idea that wisdom comes from experience, learning, and the ability to accept that one has erred (or observed another who erred) and change one's practice, the latter being a sign of medical wisdom.

So back to the initial question: When do physicians reach their peak? It may vary a bit by specialty, but my guess is that most physicians are at their best and have reached their balanced peak in the span of their forties and fifties. They may reach their peak of technical skill, knowledge base, or intellectual curiosity earlier, but wisdom is like a fine red wine, it takes longer to develop. I have known physicians who remained at or near that peak in all three qualities well into their sixties, but more often there is a decline in stamina or enthusiasm, or distraction with other duties that causes slippage; slippage in one area may be mitigated if the pillar of wisdom stays strong and a humble mind stays open.

Of course, some of this speculation is autobiographical. In my own case, I thought I was the best pediatric hematologist-oncologist on earth in my 30s, a clear lack of humility. I believe I reached my peak as a physician in my early 40s and remained close to that level until about a decade later. I accrued administrative responsibility by then and eventually started to lose track of antibiotic doses and much of my imaging skill due to lack of use. The fellows and nurse practitioners knew more about many details than I did.

When I left St. Jude in my mid-50s for an administrative role at Memorial Sloan Kettering, I realized I could not and should not assume primary responsibility for patients because of this decline, but mostly because I was undertaking a full time administrative job and would not be readily available to patients and families. Happily, I found I could still think about and discuss clinical problems clearly (as in rounds and conferences) and retained what I believe was good judgment for quite a while; technical day-to-day bedside knowledge declined first and analytic wisdom faded last.

It is humbling to realize that, in my view, despite all my training and experience and study I was at my very best as a physician for only a decade or two. I like to think I was pretty good before and after that period, but who can say? Certainly not I. Humility is the only one of the three pillars that I believe has continued to grow in my case. A review like this is one reason why.


Tuesday, January 10, 2017

Most oncologists get phone calls from relatives or friends about someone who has been diagnosed with cancer. Trying to be helpful, they suggest the friend or relative contact "my cousin (or uncle or classmate), the oncologist" for advice. They call and typically, we are told a sketchy story with so little information that we cannot provide even superficial comments or advice. The call often ends with our saying, "she is in good hands," or "he lives very near to (I name a good cancer program) if he wants another opinion." On occasion, we get more detailed information and face the difficult task of offering counsel without destroying the patient's confidence in the attending physician.

Less often in my own experience, my relative or friend passes on a request that I speak with the patient or spouse of the patient. These patients almost always have widespread cancer unresponsive to therapy. If it is clear from the discussion that the patient seems to be in good hands and that critical decisions must be made among difficult choices, I always honor the request.

First, what the patient or spouse (with the patient listening) asks is whether there is any other treatment out there that could help. But there is an unspoken understanding that their question also concerns the imminence of death and what course they should take. This is hard to do on the phone, some would say foolhardy. But if it seems right from what I have learned and the rapport is appropriate, I tell them what I think. Sometimes this means recommending the patient get his affairs in order, arrange for management to relieve pain or other problems, consider hospice care, and spend as much time at home with family as possible. In effect, I often confirm what their doctors had said, that the patient would die in the not-too-distant future.

The art of telling someone they will die does not come naturally. It requires confidence and experience and wisdom. I cannot explain these qualities with sufficient clarity to help someone else do it. The approach is sui generis, adapted to the teller's and the recipient's character, knowledge, and personality. It never gets easier…in fact, it may become harder as one ages.

Having to relate this opinion, and having done it all too often in my first years as a pediatric oncologist, has led me to read a great deal about death and dying over the years and to this day.

Unavoidably, it causes me to think about my own mortality. Philosophers, theologians, psychologists, and novelists have written reams about death. Many try to rationalize death in some way. They and I are looking for solace or some mechanism for facing the death of a patient or relative or friend or oneself.

I have found some understanding and a dash of comfort from these sources, but I am most touched by the poets who can, in a few words, contain volumes about the human condition, death being an integral part. The poet's oblique and figurative approach to the subject sometimes makes much more sense than the direct and rational. Here are two poems on the subject by Billy Collins, of whom I am an avid fan; he is a former Poet Laureate of America.

My Number

Is Death miles away from this house,

reaching for a window in Cincinnati

or breathing down the neck of a lost hiker

in British Columbia?


Is he too busy making arrangements,

tampering with air brakes,

scattering cancer cells like seeds,

loosening the wooden beams of roller coasters

 

to bother with my hidden cottage

that visitors find so hard to find?

 

Or is he stepping from a black car

parked at the dark end of the lane,

shaking open the familiar cloak,

its hood raised like the head of a crow,

and removing the scythe from the trunk?

 

Did you have any trouble with the directions?

I will ask, as I start talking my way out of this.

Collins thinks about death and with a few strokes describes the human condition and the mystery, apparent randomness, and loneliness of death. He wrote another poem about death inspired by a quote by Juan Ramón Jiménez: "The worst thing about death must be the first night." He explores the mystery of death and the feebleness of our ability to imagine or describe it with our catalogue of words.

First Night

before I opened you, Jiménez,

it never occurred to me that day and night

would continue to circle each other in the ring of death,

 

but now you have me wondering

if there will also be a sun and a moon

and will the dead gather to watch them rise and set

 

then repair, each soul alone,

to some ghastly equivalent of bed.

Or will the first night be the only night,

 

a darkness for which we have no other name?

How feeble our vocabulary in the face of death,

how impossible to write it down.

 

This is where language would stop,

the horse we have ridden all our lives

nearing the edge of a dizzying cliff.

The word that was in the beginning

and the word that was made flesh—

those and all the other words will cease.

 

Even now, reading you on this trellised porch,

how can I describe a sun that will shine after death?

But it is enough to frighten me

 

into paying more attention to the world's day—moon,

to sunlight bright on water

or fragmented in a grove of trees,

 

and to look more closely here at these small leaves,

these sentinel thorns,

whose employment is to guard the rose.​

Finally, after puzzling over what is beyond death and the futility of words to describe that mystery, he returns in the last three stanzas to earth to focus on what he can appreciate that is here, the beauty and the mysteries that are closer to home. A good lesson for me, too.


Monday, December 12, 2016

I wrote this column 1 week before our Presidential Election. I have been surprised at the paucity of health care policy discussion since it represents such a large part of the national budget. The only policy

I have heard is the Republican desire to kill Obamacare, and even little of that. Furthermore, discussions, when they have happened, have dealt with macroeconomics—the national cost and inefficiencies of medical care and proposed solutions, largely through changes in public policy.

But as a physician-oncologist, I believe in discussions about cancer care (including the unfortunately-named "Moonshot" effort, which has lofty goals but, as yet, no plan) to eradicate deaths and suffering from cancer. But, ultimately, I believe they must begin and end with patients and what is effective, efficient, and prudent for them.

We think we know, but sometimes our medical biases and economic interests get in the way. So I culled through my files on medical policy and the doctor-patient interface; some are years old but not much has changed. (I first mentioned this article in 2007.)

Unbalanced Cancer Care

The contrast of health care, quality, and cost in other countries is helpful when trying to grasp the problems. An article in the Wall Street Journal by Peter Landers (Jan. 11, 2007) on the intersection of health care policy and the patient was the seed for this essay; it is very instructive. The article was inspired by a speech made by Takashi Yamamoto to a session of the Japanese parliament. He announced to his fellow members that he had cancer and then he proceeded to denounce the nation's standard of cancer care. He pointed out that cancer is the No. 1 cause of death in Japan and that one in two Japanese will contract cancer and one in three will die of the disease. The article points out that the death rate from cancer in Japan has continued to climb since 1995, while it has slowly but steadily declined in the U.S. In 2004, annual Japanese deaths per 100,000 from cancer far exceeded the number in this country.

Yamamoto continued: "However, the level of cancer care differs among regions and facilities. Even when there are treatments [available], people are being told they will never get better. These abandoned 'cancer refugees' are roaming the Japanese archipelago. The health and labor ministry has set up an office for cancer policy…yet unfortunately it doesn't even have a grasp of…what level of care is being offered across the country." (We also don't have a sound and useful grasp of the quality of cancer care in our country.)

Yamamoto then spoke against Japan's low-cost medical system (reimbursement rates are typically lower than in the U.S.). "If we cut reimbursement rates any more, we will accelerate the departure from the health care front line of medical professionals, who are already suffering from overwork out of a sense of mission. Take a look at the medical expenses on the receipt you receive at the hospital. The fees for expert services…how low they are. We need to have more flexibility in setting reimbursement rates, and we need to take a fresh look at expensive items such as foreign drugs and medical equipment. Some in the government are studying a further cut in reimbursements. This will lead to the destruction of health care. (Amen, Mr. Yamamoto.) We must recognize that health care and nursing care contribute to the regional economies and create jobs."

Japan's View

So what was the response to this speech? Masaharu Nakajima, MD, a surgeon who once treated cancer patients and until recently was head of the Health Bureau of the Ministry of Health, Labor and Welfare, says Japan already offers excellent care. Mr. Yakamoto, a cancer patient and high level politician disagrees. He said that with the large national debt and corporations worried about higher taxes, Japan can't afford to throw money into treatments and training that offer little hope of significantly extending lifespans.

"If we keep going like this, Japan is going to be crushed under medical expenses." (If Nakajima is a representative of oncologists in Japan, it is a sad day for the medical profession and its values.) Concerning the demand for more medical specialists, Nakajima responded, "America did too much of this and that's why their medical costs have grown." (Our successes in treating cancer have grown even more. I wonder if Nakajima would have the same attitude if he got a serious cancer.)

The article then provides a framework for this Japanese debate. Health care spending in Japan is roughly one-half what it is in the U.S. and even lower than in Canada and Western European countries.

However, Japan has the highest life expectancy in the world for women and the fourth highest for men, and it has one of the lowest infant mortality rates. Since introducing universal health insurance coverage around 1960, its policy has focused on providing a minimum standard of care for all. Japanese citizens and Japanese industry must pay monthly health insurance fees, but the central government sets the rules and reimbursement rates. However, unlike England, the doctors are in private practice, not government employees. In the WSJ article, Landers also points out that surgeons have an even greater role in determining the course of therapy than in the U.S., including whether chemotherapy is given.

Another important cultural issue was illustrated thus: Shintaro Abe, a politician and the father of Japan's Prime Minister at that time, Shinzo Abe, was widely known to have cancer for 2 years before his death in 1991, but he was not told he had pancreatic cancer until 2 months before his death. Withholding the diagnosis is common in Japan (19th century attitudes).

Thus, the health care culture in Japan differs substantially from other economically strong countries from many angles. There is emerging change, mainly among patients. Cancer patients are organizing and pushing for changes in accessibility to care and to effective new drugs. In May 2005, 2,000 cancer patients had their first meeting in Osaka. One of its organizers, Shoichi Miura, a physician and cancer patient, gave a speech recalling the rallying image of "cancer refugee" (gan nanmin). "While Japan has become economically prosperous, cancer patients are in the same position as refugees who wander in search of food, water and someone who can help." He died 7 months later.

These efforts have borne some fruit. In April 2006, for the first time, 47 doctors who passed a rigorous exam were certified as oncologists qualified to administer chemotherapy. But the government continues to reduce reimbursement and increase co-payments by patients.

Nakajima, the former health official, reflecting the government attitude, is opposed to raising reimbursements because corporate "executives want to keep costs down." He also says that a diligent surgeon who bones up on the latest literature can do just as good as a licensed oncologist (no multidisciplinary teams there).​

Solving Cancer Issues

Rather than react with smug superiority to the Japanese system, I was struck by how many of the issues are the same in our country.

How do we balance the inherent conflict between patients' desire to obtain any care they wish and how to pay for such an open-ended system? How effective must therapy be to warrant financial support and who is to decide what therapy is effective? And how do we balance medically effective and cost effective? How do we assure patients a high standard of quality cancer care regardless of where they live? How do we assure the same standard of care for the economically disadvantaged? What are the appropriate statistics for making policy decisions in cancer care? Do longevity and infant mortality always trump other measures?

More than academic discussions of medical economics, this story highlights the issues faced by patients and policy makers. Japan's approach makes economic sense and is supported by their excellent health statistics for longevity and infant mortality, and by their strong and highly competitive economy.

But the rapidly aging Japanese populace and the related increase in cancer mortality have raised awareness to several aspects of human nature that they must deal with. Cancer is the most feared disease in economically advanced countries, Japan included. Because of this fear, cancer patients, compared to those with most other diseases, seem even more desperate for some hope to hang on to. This extraordinary fear has good and bad consequences. The good—patients often become very knowledgeable about their cancer, they are often willing to try new agents, and some become active in advocacy groups that raise awareness and funds for research and care. The bad—cancer patients in their desperation are highly vulnerable to the "try anything" approach offered by well-meaning physicians (or by charlatans), even if the approach has no rational chance of making patients' remaining days better.

We in oncology have not systematically addressed these very human issues of fear and hope. On the one hand, there is extraordinary fear and the vulnerability it creates, and on the other, how to offer reasonable hope based on intermediate goals when cure or remission is not in the cards. We need a better understanding and better tools for helping patients deal with their fears. We must not abandon patients once we know they will not respond to more cancer therapy. We must offer other kinds of hope without making the patients' remaining time a constant misery. We must always be "someone who can help."


Monday, November 28, 2016

This is the third in a series begun nearly a decade ago concerning lies and truth told to patients and families by medical caregivers. This version of the third and final entry has been updated and lightly edited.

At the beginning, I had read three articles published in the medical literature that dealt with physicians' candor and "truth-telling." I was reminded of Pontius Pilate. In the Gospel of John, this Roman political leader was asked to decide whether Jesus should be executed. He believed Jesus had committed no capital crime. When he questioned Jesus about his actions, Jesus said that he was there to bear witness to the truth. Pilate famously responded, "What is truth?" and ultimately agreed to have him executed to placate the angry and powerful crowd. Christian tradition vilifies him because he chose to sacrifice one powerless innocent man for political reasons. But there is a little bit of Pontius Pilate in all of us, as these articles attest.

Lindsay Rockwell, DO, an oncology fellow, wrote a heartfelt essay (J Clin Oncol 2007;25:454-455) that laments the lack of "truth-telling" in oncology, particularly when it comes to the issue of death. She describes a young man with myelodysplastic syndrome and his father. The father complained to her that no one had told the family that the young man was dying, despite the short remissions and the inevitability of death. She is dismayed that death was not discussed and instead the discussions concerned additional therapy, none likely to succeed.

Her essay was followed by a commentary written by Timothy Moynihan and Linda Schapira. They express concern at the potential damage failing to communicate can do and that we often do not prepare our young physicians sufficiently in this art. But though they are in general agreement with the major points of the essay, they wonder whether the father was told but didn't hear the information, whether Rockwell was present for all discussions, or whether the father refused to give up and would not to face the reality of the impending death of his son. They even wonder, "Could it be that Rockwell is expressing her own grief as guilt for not speaking up when she saw the inevitable truth?"

What Is Truth?

Farr Curlin, MD, and colleagues conducted a random survey of physicians in all types of practice by mail and received 1,144 responses to questions devised to determine the physicians' judgments about their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for ethical or religious reasons (N Engl J Med 2007;356:593-600). Examples are abortion for failed contraception, giving terminal sedation to dying patients, and prescribing birth control to adolescents without parental consent. (The authors report that 52% of all respondents had ethical or religious objections to abortion for failed contraception.)

Most physicians responded that all doctors have an obligation to present all options (86%), that it is ethically permissible for doctors to explain to patients their moral objections (63%), but that they should then refer patients to another physician that has no objection to the requested procedure (71%). The authors then estimated the number of patients affected by the minority, if generalized to the entire population. They conclude that 40 million-100 million Americans have physicians who feel no obligation to present all options or who would not explain that they have moral or religious objections to the procedure and feel no obligation to refer them to a more agreeable physician.

Without questioning the sincerity and conviction of the respondents, we may ask who is more truthful, a physician who believes on ethical grounds that abortion for failed contraception is always wrong and doing anything to abet the procedure is also wrong, or the physician who believes abortion is wrong, but also holds that he cannot impose his views on patients so helps them find a willing physician? One could argue that the first is more truthful to his convictions and the second more truthful with the patient. One could also argue that the physician's first obligation is to the patient's well-being, so he must help the patient obtain the procedure she desires, even though he thinks it wrong. The counterargument is that if he believes abortion in this case is murder, that he has no choice but to avoid abetting the patient.

Telling the Truth

The third article by David Studdert, LLB, ScD, MPH, and colleagues takes an economic look at telling the truth (Health Aff J 2007;26:215-226). They asked whether full disclosure of adverse outcomes actually reduces the providers' liability exposure, as some believe. They tested this theory by modeling the litigation consequences of disclosure. They compiled data on the historical frequency of litigation when the patient suffers a severe medical injury, both when due to negligence and when not. To obtain an estimate of the net impact of litigation, the authors polled 78 experts in patient safety, risk management, malpractice liability insurance, and plaintiff litigation, including lawyers on both sides. They defined serious injury as that which leaves the patient with a permanent disability or with a temporary disability that is very severe while it lasts.

They concluded from their study that, among patients whose severe injury was due to negligence, full disclosure would deter 32 percent of patients from suing and would prompt claims by 31 percent of those who would not otherwise have sued. Among patients whose injury was not due to negligence, disclosure would deter 57 percent of those who would have sued and prompt 17 percent of those who would not have sued. Overall, the experts predicted there was a 5 percent chance that the volume of claims would decline or remain the same and a 95 percent chance they would increase; the predicted outcome of compensation cost was the same, a 6 percent chance of declining and a 94 percent chance of increasing.

The authors make a key point: about 80 percent of all serious injuries due to negligence never trigger litigation. Thus, there is a huge reservoir of unlitigated injuries meaning that a small shift in that group could have much greater financial repercussions for doctors, hospitals, and insurers than the deterrence from suing of an equal percentage of patients. Though the authors predict that full disclosure would cause an expansion of litigation and monetary consequences of potentially great magnitude, they do not say, "don't tell the patient if not forced to."

The main audience of the report is policy makers, cautioning them to consider the consequences of full disclosure policies. They point out the broad consensus that disclosure of unanticipated outcomes is desirable because, as in other industries such as aviation, openness about error is critical to development of effective prevention. They continue, "there are also compelling ethical reasons for telling patients the truth about all aspects of their care."

So what will policy makers in government, the private health industry, and medical practices do? A cynic will say they will continue to follow traditional risk management procedures, which does not include full disclosure, to contain litigation costs and overall health costs. The optimist will say they will do the right thing, full disclosure, so errors may be addressed and corrected and improve the quality of care.​

So, What Is Truth?

I am confident that every reader has opinions about each of these circumstances and I am equally confident that the most of those opinions are strongly held. But as is true for discussions of politics and religion, such case studies as those presented above often don't allow room for subtleties on any side for fear of taking a step onto a slippery slope that endangers one's bedrock principle. One may hold a bedrock principle, but the specific circumstances tend to be messy and influenced by the many complexities of day-to-day living and by our own internal conflicts.

We each have a moral/ethical compass formed by our parents, culture, education, and religious faith, or lack of it. However, these positions are not immutable; they can be modified by preachers, scientists, literature, travel, and other external influences, as well as by experience and the greater wisdom (we hope) that comes with age. But we still make "right" and "wrong" decisions.

So, what is truth? I don't have the answer, but I have an answer for myself. Truth in dealing with patients is based on transparency with humanity and charity that attempts to ease their burden. And for life in general, I believe my professor of moral theology had it right: for each individual, a considerate, thoughtful, and well-informed conscience that takes all potential consequences seriously must be the final arbiter of right and wrong. My conscience always lets me know, at times reminding me even decades later, when I have already acted against it.